| NPI | 1063769172 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: KY 9188) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 9188) |
| Enumeration Date | 2012-08-08 |
| Last Update Date | 2023-03-23 |