| NPI | 1902598675 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30027761) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MI 1223G0001X) |
| Enumeration Date | 2023-05-22 |
| Last Update Date | 2024-11-21 |