| NPI | 1619017233 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 30777) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA 00010074) |
| Enumeration Date | 2007-02-07 |
| Last Update Date | 2016-09-13 |