| NPI | 1902990401 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: KY 5561) |
| Additional Taxonomies | 1223P0300X Dentist Periodontics (Licence: KY 567) |
| 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: KY 568) | |
| Enumeration Date | 2006-10-02 |
| Last Update Date | 2007-07-08 |