| NPI | 1255622692 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: KY 9075) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 9075) |
| Enumeration Date | 2011-04-19 |
| Last Update Date | 2022-01-20 |