| NPI | 1548507593 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: ID D-4461) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60300521) |
| Enumeration Date | 2013-01-10 |
| Last Update Date | 2013-11-25 |