| NPI | 1174955488 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DENT.DE.60668006) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 64255) |
| 1223G0001X Dentist, General Practice (Licence: AZ D008816) | |
| Enumeration Date | 2013-08-08 |
| Last Update Date | 2020-04-25 |