Individual
Inactive
Sole proprietor
Provider details
NPI number
Contact information
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
3512
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
60035128
—
KY
01
—
9181735
DORAL
KY
Enumeration date
—
Last updated
—
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