| NPI | 1710502679 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D010919) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH APP-000364488) |
| Enumeration Date | 2020-06-16 |
| Last Update Date | 2024-07-09 |