| NPI | 1205857570 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AR 3979) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MO 015680) |
| Enumeration Date | 2006-07-22 |
| Last Update Date | 2015-07-26 |