| NPI | 1619369972 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D10997) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA RR60482579) |
| Enumeration Date | 2015-02-24 |
| Last Update Date | 2019-02-20 |