| NPI | 1386792604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 10978) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE00006586) |
| Enumeration Date | 2007-01-05 |
| Last Update Date | 2007-07-08 |