| NPI | 1790915692 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO 00203779) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30-023018) |
| Enumeration Date | 2009-07-26 |
| Last Update Date | 2022-09-23 |