| NPI | 1518297613 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: WA DE 00004985) |
| Additional Taxonomies | 1223P0700X Dentist, Prosthodontics (Licence: WA DE 00004985) |
| Enumeration Date | 2010-01-12 |
| Last Update Date | 2010-01-12 |