| NPI | 1730190406 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA 3253) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 7894) |
| 1223G0001X Dentist, General Practice (Licence: WI 1807) | |
| Enumeration Date | 2006-08-10 |
| Last Update Date | 2007-07-09 |