| NPI | 1215937792 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA 5255) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: KS 5553) |
| Enumeration Date | 2005-07-27 |
| Last Update Date | 2007-07-08 |