| NPI | 1811146368 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE00010851) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 55460) |
| Enumeration Date | 2008-09-09 |
| Last Update Date | 2014-04-08 |