| NPI | 1821310673 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D9523) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60174477) |
| 1223G0001X Dentist, General Practice (Licence: MN D12663) | |
| Enumeration Date | 2010-02-22 |
| Last Update Date | 2011-02-23 |