| NPI | 1114335379 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA 60889681) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019) |
| 122300000X Dentist (Licence: NV 6857) | |
| Enumeration Date | 2014-07-31 |
| Last Update Date | 2019-02-11 |