| NPI | 1790070910 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60438408) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: IN 12011668A) |
| Enumeration Date | 2011-06-15 |
| Last Update Date | 2014-04-24 |