| NPI | 1568799070 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401413729) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30023087) |
| Enumeration Date | 2009-11-05 |
| Last Update Date | 2021-07-12 |