| NPI | 1649766593 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: OH 30026606) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 10049) |
| Enumeration Date | 2018-07-03 |
| Last Update Date | 2022-04-18 |