| NPI | 1619381472 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: WA DE60655115) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60655115) |
| Enumeration Date | 2014-06-19 |
| Last Update Date | 2016-11-07 |