| NPI | 1063490423 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: OR D11021) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: WA 7946) |
| Enumeration Date | 2006-01-05 |
| Last Update Date | 2019-04-12 |