| NPI | 1700239035 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30.025550) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: OH RES.3668) |
| Enumeration Date | 2016-07-21 |
| Last Update Date | 2021-12-17 |