| NPI | 1881696458 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE7342) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: ID D-4796-PE) |
| Enumeration Date | 2005-08-12 |
| Last Update Date | 2019-05-08 |