| NPI | 1245330059 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: WA md00017630) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WA de00004338) |
| Enumeration Date | 2006-09-22 |
| Last Update Date | 2017-08-09 |