| NPI | 1922054964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OH 19264) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA 7443) |
| Enumeration Date | 2006-05-25 |
| Last Update Date | 2021-08-22 |