| NPI | 1376820365 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 27513) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60242044) |
| Enumeration Date | 2011-11-04 |
| Last Update Date | 2016-05-18 |