| NPI | 1154392488 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 55960) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE00009331) |
| 1223G0001X Dentist, General Practice (Licence: AZ 6984) | |
| Enumeration Date | 2006-01-26 |
| Last Update Date | 2013-09-19 |