| NPI | 1104047190 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MN D12888) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: WA 5919) |
| Enumeration Date | 2007-05-01 |
| Last Update Date | 2012-06-25 |