| NPI | 1518212661 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401413685) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60296321) |
| Enumeration Date | 2012-07-16 |
| Last Update Date | 2015-08-18 |