| NPI | 1376818211 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: ID D-4942) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60764306) |
| Enumeration Date | 2012-03-10 |
| Last Update Date | 2022-02-16 |