| NPI | 1912473190 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: OH 30.025606) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401416285) |
| Enumeration Date | 2018-10-16 |
| Last Update Date | 2022-01-10 |