| NPI | 1407289457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: WA DE60306318) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE 60306318) |
| Enumeration Date | 2013-08-14 |
| Last Update Date | 2019-02-05 |