| NPI | 1619238854 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 23705) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 23705) |
| Enumeration Date | 2012-06-05 |
| Last Update Date | 2017-04-19 |