| NPI | 1609139302 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901021388) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30-023756) |
| Enumeration Date | 2012-06-19 |
| Last Update Date | 2015-12-15 |