| NPI | 1740237064 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: KY 4461) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 4461) |
| 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: KY 4461) | |
| 1223P0221X Dentist Pediatric Dentistry (Licence: KY 4461) | |
| Enumeration Date | 2006-05-30 |
| Last Update Date | 2016-02-10 |