| NPI | 1912721150 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X2210X Dentist, Orofacial Pain (Licence: KY D-00287) |
| Additional Taxonomies | 1223X2210X Dentist, Orofacial Pain (Licence: MN FF94) |
| Enumeration Date | 2024-11-13 |
| Last Update Date | 2026-09-02 |