| NPI | 1750570313 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE00011148) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 56165) |
| Enumeration Date | 2007-10-19 |
| Last Update Date | 2011-05-31 |