| NPI | 1518905702 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE00011215) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WI 5535-015) |
| Enumeration Date | 2006-06-02 |
| Last Update Date | 2011-12-28 |