| NPI | 1902131105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE60707357) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 58814) |
| 1223G0001X Dentist, General Practice (Licence: NV 5960) | |
| Enumeration Date | 2009-10-06 |
| Last Update Date | 2020-04-29 |