| NPI | 1386903938 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: WA DE61487151) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: OR D10894) |
| 122300000X Dentist (Licence: CO 00202036) | |
| Enumeration Date | 2012-05-15 |
| Last Update Date | 2024-01-02 |