| NPI | 1467760850 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE 60462145) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MD 14600) |
| Enumeration Date | 2010-09-20 |
| Last Update Date | 2015-05-19 |