| NPI | 1205099520 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OH 30.023405) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60199807) |
| Enumeration Date | 2008-07-07 |
| Last Update Date | 2018-10-12 |