| NPI | 1639108152 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: WA DE00011116) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: PA DS035432) |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2015-11-19 |