| NPI | 1194058669 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist Periodontics (Licence: WA DE60101496) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60101496) |
| Enumeration Date | 2009-09-15 |
| Last Update Date | 2009-09-15 |