| NPI | 1790091577 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401412833) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30-023391) |
| Enumeration Date | 2010-08-31 |
| Last Update Date | 2015-04-08 |