| NPI | 1366777393 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE00003923) |
| Additional Taxonomies | 126800000X Dental Assistant (Licence: WA DE00003923) |
| Enumeration Date | 2009-10-08 |
| Last Update Date | 2009-12-19 |