| NPI | 1104019793 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: KS 60953) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: MO 2014031262) |
| Enumeration Date | 2007-08-27 |
| Last Update Date | 2024-09-14 |