| NPI | 1356372957 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE60311143) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID D4171) |
| Enumeration Date | 2006-07-05 |
| Last Update Date | 2012-10-23 |