| NPI | 1326305137 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60546323) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D13086) |
| Enumeration Date | 2012-04-18 |
| Last Update Date | 2016-10-05 |