| NPI | 1558663005 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: WA 7346) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 26919) |
| 122300000X Dentist (Licence: WI 5001730) | |
| Enumeration Date | 2010-12-03 |
| Last Update Date | 2010-12-03 |