| NPI | 1841603222 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: GA DN014798) |
| Additional Taxonomies | 122300000X Dentist (Licence: GA DN014798) |
| 122300000X Dentist (Licence: PA D2040438) | |
| Enumeration Date | 2014-06-03 |
| Last Update Date | 2016-06-27 |