| NPI | 1699916585 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 28680) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA de60056279) |
| Enumeration Date | 2009-03-23 |
| Last Update Date | 2018-04-24 |