| NPI | 1588795736 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60390327) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA B38275) |
| Enumeration Date | 2007-03-08 |
| Last Update Date | 2014-02-20 |