| NPI | 1679538482 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: KY 6963) |
| Additional Taxonomies | 1223D0001X Dentist, Dental Public Health (Licence: KY 6963) |
| Enumeration Date | 2006-04-18 |
| Last Update Date | 2011-03-08 |