| NPI | 1639249121 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: KY 4670) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: KY 4670) |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: KY 4670) | |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: KY 4670) | |
| Enumeration Date | 2006-11-09 |
| Last Update Date | 2014-01-23 |