| NPI | 1619040995 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: KY 8102) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: KY KY8102) |
| 122300000X Dentist (Licence: KY 8102) | |
| Enumeration Date | 2006-11-16 |
| Last Update Date | 2013-08-23 |