| NPI | 1730571043 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30.024686) |
| Additional Taxonomies | 122300000X Dentist (Licence: NY 057670-1) |
| Enumeration Date | 2015-02-23 |
| Last Update Date | 2018-09-10 |