| NPI | 1316935570 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: KY 6253) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 6253) |
| Enumeration Date | 2005-10-12 |
| Last Update Date | 2013-11-05 |