| NPI | 1053574319 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60932717) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 23529) |
| Enumeration Date | 2008-07-08 |
| Last Update Date | 2019-12-10 |