| NPI | 1457787244 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D10092) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE 60373461) |
| Enumeration Date | 2013-09-24 |
| Last Update Date | 2014-07-22 |