| NPI | 1083967467 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE 60306500) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D9792) |
| 122300000X Dentist (Licence: NV 6352) | |
| Enumeration Date | 2012-10-22 |
| Last Update Date | 2022-07-01 |