| NPI | 1174681753 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: OR D7292) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60187373) |
| 1223G0001X Dentist General Practice (Licence: ID D3705) | |
| Enumeration Date | 2006-12-05 |
| Last Update Date | 2018-12-05 |