| NPI | 1275603482 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: NV 4549) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA 60386595) |
| Enumeration Date | 2006-11-08 |
| Last Update Date | 2013-10-01 |