| NPI | 1003986977 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 28811) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: WA DE00007394) |
| Enumeration Date | 2006-11-08 |
| Last Update Date | 2013-07-25 |