| NPI | 1588979967 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE 60189640) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 25997) |
| 1223G0001X Dentist, General Practice (Licence: WA 60189640) | |
| Enumeration Date | 2010-08-10 |
| Last Update Date | 2020-12-14 |