| NPI | 1104019793 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: KS 60953) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 6620034-9921) |
| Enumeration Date | 2007-08-27 |
| Last Update Date | 2017-03-31 |