| NPI | 1073821286 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WA 60204550) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: IL 019.028413) |
| Enumeration Date | 2010-09-22 |
| Last Update Date | 2014-07-28 |