| NPI | 1821083296 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NC 8909) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30-21691) |
| 1223G0001X Dentist, General Practice (Licence: FL 18444) | |
| Enumeration Date | 2005-09-13 |
| Last Update Date | 2011-09-01 |