| NPI | 1477846780 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: KY 9043) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 9043) |
| Enumeration Date | 2011-05-18 |
| Last Update Date | 2018-11-27 |