| NPI | 1174677009 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE 60200022) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 51611) |
| Enumeration Date | 2007-01-22 |
| Last Update Date | 2016-11-03 |