| NPI | 1487758835 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE 60446913) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AL 4631) |
| Enumeration Date | 2006-09-07 |
| Last Update Date | 2015-07-16 |