| NPI | 1417357898 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 30706) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE 60496761) |
| Enumeration Date | 2014-09-03 |
| Last Update Date | 2021-01-06 |