| NPI | 1659800308 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30025134) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS041322) |
| Enumeration Date | 2017-06-07 |
| Last Update Date | 2018-03-17 |