| NPI | 1790197390 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: OH 30.025178) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: MA DN1856531) |
| Enumeration Date | 2014-05-30 |
| Last Update Date | 2019-07-09 |