| NPI | 1588911127 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry (Licence: WA DF60285860) |
| Additional Taxonomies | 1223X0008X Dentist Oral and Maxillofacial Radiology (Licence: WA DF60285860) |
| Enumeration Date | 2012-08-14 |
| Last Update Date | 2012-08-14 |