| NPI | 1124486675 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: KS 61356) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: KS 61356) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-01-28 |
| Last Update Date | 2022-07-21 |