| NPI | 1821413253 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60660218) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.024114) |
| Enumeration Date | 2014-02-21 |
| Last Update Date | 2017-01-06 |