| NPI | 1376011486 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60890263) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA 60890263) |
| Enumeration Date | 2018-11-06 |
| Last Update Date | 2019-01-03 |