| NPI | 1669858643 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: FL DN21275) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30-024442) |
| Enumeration Date | 2015-08-03 |
| Last Update Date | 2024-05-15 |