| NPI | 1396030151 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 6688-15) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: WI 6688-15) |
| Enumeration Date | 2011-06-09 |
| Last Update Date | 2015-03-06 |