| NPI | 1538323613 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D10061) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60013040) |
| Enumeration Date | 2008-07-17 |
| Last Update Date | 2015-01-21 |