| NPI | 1982990891 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: WA DE60356126) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60356126) |
| 122300000X Dentist (Licence: OH RES 3068) | |
| Enumeration Date | 2011-06-20 |
| Last Update Date | 2018-10-30 |