| NPI | 1306816582 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE00010794) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MO DE 014589) |
| Enumeration Date | 2006-01-23 |
| Last Update Date | 2012-04-02 |