| NPI | 1376863035 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: AR 3932) |
| Additional Taxonomies | 122300000X Dentist (Licence: LA 6051) |
| 1223G0001X Dentist, General Practice (Licence: LA 6051) | |
| 1223G0001X Dentist, General Practice (Licence: AR 3932) | |
| Enumeration Date | 2010-06-04 |
| Last Update Date | 2013-06-24 |