| NPI | 1790348852 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: NC 12175) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30.026063) |
| Enumeration Date | 2019-04-15 |
| Last Update Date | 2021-06-07 |