| NPI | 1962885608 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: KY 10083) |
| Additional Taxonomies | 122300000X Dentist (Licence: IN 12012371A) |
| 122300000X Dentist (Licence: TX 31235) | |
| 122300000X Dentist (Licence: OH 30.24700) | |
| Enumeration Date | 2015-06-30 |
| Last Update Date | 2018-05-31 |