| NPI | 1649460643 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60119967) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID D-4090) |
| Enumeration Date | 2007-07-26 |
| Last Update Date | 2022-07-14 |