| NPI | 1790168029 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE 60647527) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NE 7248) |
| Enumeration Date | 2015-07-06 |
| Last Update Date | 2016-07-13 |