| NPI | 1063416725 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: WA 4267) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: AK 1014) |
| Enumeration Date | 2005-06-10 |
| Last Update Date | 2007-07-08 |