| NPI | 1316019995 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223D0004X Dentist, Dentist Anesthesiologist Speciality (Licence: TX 28856) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA 10618) |
| Enumeration Date | 2006-11-15 |
| Last Update Date | 2016-04-04 |