| NPI | 1588896682 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30.027994) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 27247) |
| 1223G0001X Dentist, General Practice (Licence: TX 27247) | |
| Enumeration Date | 2009-08-23 |
| Last Update Date | 2025-09-02 |