| NPI | 1548954555 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: OR D12311) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30.027146) |
| Enumeration Date | 2023-06-05 |
| Last Update Date | 2026-06-01 |