| NPI | 1568661502 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00008888) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30021905) |
| Enumeration Date | 2007-07-11 |
| Last Update Date | 2020-03-16 |