| NPI | 1649457300 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30.022906) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 2901019909) |
| Enumeration Date | 2008-01-24 |
| Last Update Date | 2025-11-03 |