| NPI | 1902081656 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 30830) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OH 30.016462) |
| Enumeration Date | 2007-12-31 |
| Last Update Date | 2007-12-31 |