| NPI | 1588047385 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30.24806) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH RES.3606) |
| Enumeration Date | 2015-06-30 |
| Last Update Date | 2018-06-03 |