| NPI | 1104806918 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: WA 6738) |
| Additional Taxonomies | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: WA 6738) |
| Enumeration Date | 2006-01-18 |
| Last Update Date | 2007-07-08 |