| NPI | 1588856652 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE00011082) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ D009161) |
| Enumeration Date | 2007-08-13 |
| Last Update Date | 2015-05-06 |