| NPI | 1629246285 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30.023226) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AZ 7239) |
| Enumeration Date | 2008-02-18 |
| Last Update Date | 2013-06-19 |