| NPI | 1881924959 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: KY 844) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: KY 8835) |
| Enumeration Date | 2010-01-12 |
| Last Update Date | 2010-02-09 |