| NPI | 1104804186 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223E0200X Dentist, Endodontics (Licence: WA DE00009800) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE00009800) |
| 122300000X Dentist (Licence: UT 5325919-9921) | |
| 122300000X Dentist (Licence: NV 5595) | |
| Enumeration Date | 2006-01-09 |
| Last Update Date | 2010-06-21 |