| NPI | 1972739118 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: OH 30.023387) |
| Additional Taxonomies | 1223P0221X Dentist Pediatric Dentistry (Licence: TX 27906) |
| 122300000X Dentist (Licence: OH 30.023387) | |
| Enumeration Date | 2009-06-02 |
| Last Update Date | 2017-11-08 |