| NPI | 1275526972 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: ID D-3737) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE 00009590) |
| Enumeration Date | 2005-08-26 |
| Last Update Date | 2010-12-06 |