| NPI | 1356641161 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: WA DE60282727) |
| Additional Taxonomies | 122300000X Dentist (Licence: MA DN1855544) |
| Enumeration Date | 2010-10-26 |
| Last Update Date | 2012-09-07 |