| NPI | 1407379639 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D10675) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA 60760032) |
| Enumeration Date | 2017-07-19 |
| Last Update Date | 2020-08-07 |