| NPI | 1104293877 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE60938377) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2015018855) |
| Enumeration Date | 2015-08-28 |
| Last Update Date | 2020-03-16 |