| NPI | 1568748911 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: ID D-4395) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE 60251455) |
| Enumeration Date | 2011-10-31 |
| Last Update Date | 2012-07-23 |