| NPI | 1891360905 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901600879) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.026495) |
| Enumeration Date | 2021-05-21 |
| Last Update Date | 2023-04-24 |