| NPI | 1376814178 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: WA 60555443) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MI 2901020533) |
| Enumeration Date | 2012-01-25 |
| Last Update Date | 2019-07-29 |