| NPI | 1568718518 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 11669) |
| Additional Taxonomies | 122300000X Dentist (Licence: SC 9495) |
| 122300000X Dentist (Licence: OH 30.023810) | |
| Enumeration Date | 2012-07-27 |
| Last Update Date | 2026-05-04 |