| NPI | 1811367030 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: KY 10231) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30-024552) |
| Enumeration Date | 2015-09-30 |
| Last Update Date | 2022-07-22 |