| NPI | 1083099519 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60837881) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 31273) |
| Enumeration Date | 2015-07-27 |
| Last Update Date | 2018-06-18 |