| NPI | 1225388606 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE60301991) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60301991) |
| 1223P0700X Dentist, Prosthodontics (Licence: WA DE60301991) | |
| Enumeration Date | 2012-09-13 |
| Last Update Date | 2015-01-21 |