| NPI | 1790075349 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: KY 9046) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 9046) |
| Enumeration Date | 2011-04-17 |
| Last Update Date | 2013-09-25 |