| NPI | 1972984730 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO DEN.00202763) |
| Additional Taxonomies | 122300000X Dentist (Licence: OH 30.024524) |
| Enumeration Date | 2015-06-17 |
| Last Update Date | 2025-05-06 |