| NPI | 1487611406 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: KY 4300) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: KY 4300) |
| Enumeration Date | 2006-04-26 |
| Last Update Date | 2007-07-09 |