| NPI | 1477546570 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D8733) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE00009370) |
| 1223G0001X Dentist, General Practice (Licence: NM DD2753) | |
| Enumeration Date | 2005-08-24 |
| Last Update Date | 2007-10-29 |