| NPI | 1790882819 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE00010128) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA CA50735) |
| 122300000X Dentist (Licence: MI 2901019302) | |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2012-09-04 |