| NPI | 1063675767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: KY 8275) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WA DE 60220460) |
| Enumeration Date | 2008-07-03 |
| Last Update Date | 2011-07-05 |