| NPI | 1629150198 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: WA DE00006928) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 37884) |
| 1223G0001X Dentist General Practice (Licence: OR D6622) | |
| Enumeration Date | 2006-10-20 |
| Last Update Date | 2007-07-08 |