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 |