| NPI | 1417977893 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D6061) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA 5990) |
| Enumeration Date | 2006-07-20 |
| Last Update Date | 2016-01-05 |