| NPI | 1558128066 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: KS 62277) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.027536) |
| Enumeration Date | 2024-03-01 |
| Last Update Date | 2025-01-07 |