| NPI | 1043207004 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: CT 12339) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE00009227) |
| Enumeration Date | 2005-10-04 |
| Last Update Date | 2019-10-16 |