| NPI | 1942305610 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: ID D4012) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA 60028773) |
| Enumeration Date | 2006-09-14 |
| Last Update Date | 2016-07-29 |