| NPI | 1366568263 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA 60634931) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 20113) |
| Enumeration Date | 2007-03-22 |
| Last Update Date | 2019-06-19 |