| NPI | 1679814479 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OH RES.3360) |
| Additional Taxonomies | 122300000X Dentist (Licence: NE 7091) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2013-03-05 |
| Last Update Date | 2013-08-26 |