| NPI | 1558575985 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: KY 8305) |
| Additional Taxonomies | 122300000X Dentist (Licence: IN 12013294A) |
| 1223G0001X Dentist General Practice (Licence: OH 30-022185) | |
| Enumeration Date | 2007-05-08 |
| Last Update Date | 2021-02-12 |