| NPI | 1720484801 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60692450) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D10454) |
| 1223G0001X Dentist, General Practice (Licence: CA 63553) | |
| Enumeration Date | 2014-11-17 |
| Last Update Date | 2016-10-11 |