| NPI | 1700947702 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE00008497) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 26856) |
| Enumeration Date | 2006-12-13 |
| Last Update Date | 2007-07-08 |