| NPI | 1811252166 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE 60316229) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO 201793) |
| Enumeration Date | 2012-07-11 |
| Last Update Date | 2013-09-19 |