| NPI | 1366715120 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: WA DE60453832) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 10316) |
| Enumeration Date | 2012-02-09 |
| Last Update Date | 2016-08-07 |