| NPI | 1124462924 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: LA 6150) |
| Additional Taxonomies | 1223E0200X Dentist, Endodontics (Licence: WA DE60364992) |
| Enumeration Date | 2013-04-23 |
| Last Update Date | 2018-07-10 |