| NPI | 1710047410 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D8513) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE00010445) |
| Enumeration Date | 2006-12-11 |
| Last Update Date | 2015-12-28 |