| NPI | 1336369982 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60079105) |
| Additional Taxonomies | 122300000X Dentist (Licence: NH 3513) |
| 122300000X Dentist (Licence: MA 21471) | |
| Enumeration Date | 2007-04-26 |
| Last Update Date | 2021-12-08 |