| NPI | 1275671208 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: KY 6359) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 6359) |
| 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: KY 6359) | |
| Enumeration Date | 2007-02-02 |
| Last Update Date | 2015-04-20 |