| NPI | 1912350257 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60867841) |
| Additional Taxonomies | 122300000X Dentist (Licence: MN D13743) |
| 122300000X Dentist (Licence: UT 9740713) | |
| 1223G0001X Dentist, General Practice (Licence: WA DE60867841) | |
| Enumeration Date | 2016-07-21 |
| Last Update Date | 2018-09-20 |