| NPI | 1710262936 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60606761) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 81213469921) |
| Enumeration Date | 2011-10-19 |
| Last Update Date | 2016-01-18 |