| NPI | 1275769432 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401413269) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60096175) |
| Enumeration Date | 2009-06-02 |
| Last Update Date | 2012-06-21 |