| NPI | 1619407053 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: SC 10284) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 9970) |
| 122300000X Dentist (Licence: SC 10148) | |
| 1223G0001X Dentist, General Practice (Licence: KY 9970) | |
| Enumeration Date | 2017-06-18 |
| Last Update Date | 2022-07-08 |