| NPI | 1255459640 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE 00011198) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NY 051559) |
| Enumeration Date | 2007-03-26 |
| Last Update Date | 2021-03-03 |