| NPI | 1114362258 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60361349) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: ID D-4527) |
| Enumeration Date | 2013-05-02 |
| Last Update Date | 2018-11-30 |