| NPI | 1265760474 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: WA de00011114) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: ID D-4283-PE) |
| Enumeration Date | 2009-11-28 |
| Last Update Date | 2020-04-15 |