| NPI | 1013235522 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA 60890587) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MD 14903) |
| 1223G0001X Dentist, General Practice (Licence: CA 58826) | |
| 1223G0001X Dentist, General Practice (Licence: CO 9988) | |
| Enumeration Date | 2010-05-07 |
| Last Update Date | 2018-10-11 |