| NPI | 1528704129 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901602774) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.027083) |
| Enumeration Date | 2022-05-07 |
| Last Update Date | 2025-08-10 |