| NPI | 1902466329 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: KY 10647) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: UT 11338411-9922) |
| 1223G0001X Dentist, General Practice (Licence: OH 30.026176) | |
| Enumeration Date | 2019-06-18 |
| Last Update Date | 2021-06-24 |