| NPI | 1518273143 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D008539) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE 60162901) |
| Enumeration Date | 2010-08-20 |
| Last Update Date | 2021-11-02 |