| NPI | 1508050923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE 60178653) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 9475DDS) |
| Enumeration Date | 2007-08-29 |
| Last Update Date | 2011-06-20 |