| NPI | 1306399233 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: WA DE60896607) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: OR D10514) |
| Enumeration Date | 2016-07-27 |
| Last Update Date | 2018-12-06 |