| NPI | 1043290067 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60083251) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MN D10854) |
| Enumeration Date | 2006-01-17 |
| Last Update Date | 2009-08-13 |