| NPI | 1821420092 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30.024288) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS040140) |
| Enumeration Date | 2013-07-30 |
| Last Update Date | 2016-01-25 |