| NPI | 1184750010 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: KY 6476) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 6476) |
| Enumeration Date | 2007-02-26 |
| Last Update Date | 2015-01-20 |