| NPI | 1174754451 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE60906894) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 0024862) |
| Enumeration Date | 2009-08-04 |
| Last Update Date | 2021-02-08 |