| NPI | 1861067993 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: ID 9671742) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID 9671742) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: KY 10905) | |
| Enumeration Date | 2021-05-21 |
| Last Update Date | 2026-05-27 |