| NPI | 1801558150 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: KY 10909) |
| Additional Taxonomies | 122300000X Dentist (Licence: WV 4468) |
| Enumeration Date | 2021-10-13 |
| Last Update Date | 2023-05-09 |