| NPI | 1770997280 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30-024241) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: TX 31835) |
| Enumeration Date | 2014-06-12 |
| Last Update Date | 2016-06-10 |