| NPI | 1528323102 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental (Licence: ME DEN4832) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30-023735) |
| 1223P0700X Dentist, Prosthodontics (Licence: OH 30.023735) | |
| 1223P0700X Dentist, Prosthodontics (Licence: WI 1002001) | |
| Enumeration Date | 2012-07-10 |
| Last Update Date | 2020-11-30 |