| NPI | 1700164969 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: WA DE60231686) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: CA DDS61887) |
| 1223P0300X Dentist, Periodontics (Licence: WI 1001779) | |
| 1223P0300X Dentist, Periodontics (Licence: TX 28573) | |
| 1223P0300X Dentist, Periodontics (Licence: OR D9565) | |
| Enumeration Date | 2011-07-21 |
| Last Update Date | 2020-02-20 |