| NPI | 1013222538 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401415098) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60136990) |
| Enumeration Date | 2010-08-09 |
| Last Update Date | 2018-03-17 |