| NPI | 1396048039 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D9546) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: WA DE60175310) |
| Enumeration Date | 2010-12-20 |
| Last Update Date | 2011-01-27 |