| NPI | 1629285804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: MD 13725) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 21858) |
| Enumeration Date | 2007-05-17 |
| Last Update Date | 2013-04-30 |