| NPI | 1205997236 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: KY 8194) |
| Additional Taxonomies | 252Y00000X Early Intervention Provider Agency (Licence: KY 4500348) |
| Enumeration Date | 2006-12-13 |
| Last Update Date | 2014-08-26 |