| NPI | 1891166062 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D9719) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE9616) |
| Enumeration Date | 2015-10-14 |
| Last Update Date | 2015-10-14 |