| NPI | 1912306366 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00202622) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA RR60476044) |
| Enumeration Date | 2014-08-21 |
| Last Update Date | 2015-08-18 |