| NPI | 1720116973 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: KY 8208-800) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 8208) |
| Enumeration Date | 2007-03-01 |
| Last Update Date | 2010-08-31 |