| NPI | 1588718688 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: OH 30023883) |
| Additional Taxonomies | 1223P0221X Dentist Pediatric Dentistry (Licence: OH 30023883) |
| Enumeration Date | 2007-01-23 |
| Last Update Date | 2014-10-16 |