| NPI | 1497065551 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60434325) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 7692415-9922) |
| 1223G0001X Dentist, General Practice (Licence: OR D10029) | |
| Enumeration Date | 2010-10-07 |
| Last Update Date | 2019-02-04 |