| NPI | 1184971889 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE60729358) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 28349) |
| Enumeration Date | 2012-08-13 |
| Last Update Date | 2018-06-01 |