| NPI | 1548751902 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: KY 10085) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 10085) |
| Enumeration Date | 2018-05-22 |
| Last Update Date | 2020-01-12 |