| NPI | 1790246015 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: KY 10616) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.026059) |
| 1223G0001X Dentist General Practice (Licence: OH 30.026059) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-03-28 |
| Last Update Date | 2021-06-08 |