| NPI | 1659470268 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WY 1434) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WY 1094) |
| Enumeration Date | 2006-09-21 |
| Last Update Date | 2016-06-09 |