| NPI | 1972059178 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60792614) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: FL DN22162) |
| Enumeration Date | 2016-08-28 |
| Last Update Date | 2017-11-01 |