| NPI | 1275014839 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: FL DN23825) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60874701) |
| Enumeration Date | 2018-08-22 |
| Last Update Date | 2019-03-18 |