| NPI | 1518634625 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN27826) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30026614) |
| 1223G0001X Dentist, General Practice (Licence: FL 27826) | |
| Enumeration Date | 2021-08-26 |
| Last Update Date | 2025-04-10 |