| NPI | 1194933036 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: KY 833) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 8368) |
| Enumeration Date | 2007-05-21 |
| Last Update Date | 2012-08-30 |