| NPI | 1609157171 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223D0004X Dentist, Dentist Anesthesiologist Speciality (Licence: CO 00202224) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 3121) |
| Enumeration Date | 2011-08-29 |
| Last Update Date | 2020-08-27 |