| NPI | 1497116651 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 34339) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DR60647658) |
| Enumeration Date | 2016-03-16 |
| Last Update Date | 2018-12-28 |