| NPI | 1184900797 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: KY 956) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 9025) |
| Enumeration Date | 2011-10-26 |
| Last Update Date | 2014-09-29 |