| NPI | 1962474304 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: KY 9027) |
| Additional Taxonomies | 363AS0400X Physician Assistant Surgical (Licence: KY PA560) |
| 1223P0106X Dentist Oral and Maxillofacial Pathology (Licence: KY 9027) | |
| Enumeration Date | 2006-02-01 |
| Last Update Date | 2016-09-13 |