| NPI | 1619971413 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA de00006321) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA de00006321) |
| Enumeration Date | 2005-06-09 |
| Last Update Date | 2010-07-28 |