| NPI | 1942864392 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: MD 17741) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.025942) |
| 122300000X Dentist (Licence: CA 103799) | |
| 122300000X Dentist (Licence: PA DS042237) | |
| Enumeration Date | 2019-04-30 |
| Last Update Date | 2021-11-05 |