| NPI | 1700260650 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MT 11637) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.024471) |
| Enumeration Date | 2015-07-09 |
| Last Update Date | 2017-10-27 |