| NPI | 1942447776 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60471062) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D10185) |
| 122300000X Dentist (Licence: CA 57218) | |
| 1223E0200X Dentist Endodontics (Licence: MN S55) | |
| Enumeration Date | 2009-01-15 |
| Last Update Date | 2016-12-12 |