| NPI | 1902913965 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: WV 2716) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: OH 018722) |
| Enumeration Date | 2006-08-24 |
| Last Update Date | 2015-02-20 |