| NPI | 1528284643 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE00010837) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 16501) |
| Enumeration Date | 2007-04-17 |
| Last Update Date | 2015-05-05 |