| NPI | 1053691295 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: WA 60342409) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 27321) |
| Enumeration Date | 2011-08-19 |
| Last Update Date | 2019-03-01 |