| NPI | 1659752137 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 100064) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE 60666476) |
| Enumeration Date | 2015-06-10 |
| Last Update Date | 2019-01-23 |