| NPI | 1679914691 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE30687475) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE60387475) |
| Enumeration Date | 2013-07-08 |
| Last Update Date | 2013-10-01 |