| NPI | 1700291986 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: MI 2901021735) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.024465) |
| Enumeration Date | 2014-06-25 |
| Last Update Date | 2019-06-30 |