| NPI | 1023208857 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: VA 0438000318) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE00010956) |
| Enumeration Date | 2007-07-27 |
| Last Update Date | 2018-11-19 |