| NPI | 1396733200 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: KY 3880) |
| Additional Taxonomies | 174400000X Specialist (Licence: KY KY3880) |
| Enumeration Date | 2005-10-13 |
| Last Update Date | 2012-08-21 |