| NPI | 1538396999 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: WA DE 60514923) |
| Additional Taxonomies | 122300000X Dentist (Licence: MO 2009013997) |
| Enumeration Date | 2009-06-12 |
| Last Update Date | 2018-10-03 |