| NPI | 1972804573 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: WA DE60327979) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO 10329) |
| Enumeration Date | 2010-11-12 |
| Last Update Date | 2016-02-24 |