| NPI | 1699157305 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30.026748) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS040387) |
| Enumeration Date | 2015-06-18 |
| Last Update Date | 2022-07-12 |