| NPI | 1649792706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE60839553) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 33233) |
| Enumeration Date | 2017-07-11 |
| Last Update Date | 2018-03-19 |