| NPI | 1699975904 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: KY 8167) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: KY 8167) |
| Enumeration Date | 2007-07-24 |
| Last Update Date | 2010-08-16 |