| NPI | 1851481238 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE00010688) |
| Additional Taxonomies | 122300000X Dentist (Licence: AK 1258) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: OR D9524) | |
| Enumeration Date | 2006-10-13 |
| Last Update Date | 2018-09-14 |