| NPI | 1255463410 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE 60161571) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: AK 1090) |
| 122300000X Dentist (Licence: FL 17785) | |
| Enumeration Date | 2007-03-12 |
| Last Update Date | 2012-10-17 |