| NPI | 1205198447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: KS 61462) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60288276) |
| Enumeration Date | 2012-06-13 |
| Last Update Date | 2018-06-08 |