| NPI | 1649522194 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CO 202196) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: KY 9256) |
| 1223G0001X Dentist General Practice (Licence: OH 30-023820) | |
| Enumeration Date | 2012-10-09 |
| Last Update Date | 2014-07-07 |