| NPI | 1023228806 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: KY 5401) |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies (Licence: KY 5401) |
| Enumeration Date | 2007-05-23 |
| Last Update Date | 2019-02-20 |