| NPI | 1275969156 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE 60319906) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 64405) |
| Enumeration Date | 2013-09-23 |
| Last Update Date | 2018-05-16 |