| NPI | 1609214105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30.024057) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401414004) |
| Enumeration Date | 2013-06-06 |
| Last Update Date | 2013-08-01 |