| NPI | 1790123198 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 057454) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.024649) |
| Enumeration Date | 2013-06-06 |
| Last Update Date | 2021-06-24 |