| NPI | 1043749062 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: WA DE60774794) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 103149) |
| Enumeration Date | 2017-06-05 |
| Last Update Date | 2018-10-18 |