| NPI | 1659019842 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D012322) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30.026854) |
| Enumeration Date | 2022-05-26 |
| Last Update Date | 2026-02-27 |