| NPI | 1528692431 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D012299) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.026345) |
| Enumeration Date | 2020-02-29 |
| Last Update Date | 2025-06-16 |