| NPI | 1477006765 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60672126) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE60672126) |
| Enumeration Date | 2016-08-03 |
| Last Update Date | 2018-08-22 |