| NPI | 1164650198 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223D0004X Dentist, Dentist Anesthesiologist Speciality (Licence: WA ga60690773) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60688067) |
| 1223D0004X Dentist, Dentist Anesthesiologist Speciality (Licence: PA DS039119) | |
| Enumeration Date | 2009-06-29 |
| Last Update Date | 2021-05-25 |