| NPI | 1649671173 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE60495068) |
| Additional Taxonomies | 122300000X Dentist (Licence: KS 61031) |
| Enumeration Date | 2014-09-16 |
| Last Update Date | 2015-08-12 |