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| Credential | DDS |
| Provider Enterprise Type | Individual |
| Gender | Male |
| Provider Enumeration Date | 06/30/2018 |
| Last Update Date | 07/16/2019 |
Provider Small business Emailing Tackle Information:
| Address | 55 E 86th Avenue Ste D, |
| City | Merrillville |
| State | Indiana |
| Zip | 46410-6265 |
| Phone Number | 219-769-6424 |
| Fax Number | — |
Provider Small business Apply Location Target Information:
| Address | 55 E 86th Avenue Ste Do, |
| City | Merrillville |
| State | Indiana |
| Zip | 46410-6265 |
| Phone Number | 219-769-6424 |
| Fax Number | — |
Provider’s Primary Taxonomy Details:
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| Type | Dental Providers |
| Speciality | Dentist ( space ) Standard Practice |
| Taxonomy | 1223G0001X |
| Licence Simply no. | 12012978A (Indy) |