| NPI | 1053644104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60099952) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 59383) |
| Enumeration Date | 2009-09-08 |
| Last Update Date | 2013-05-01 |