| NPI | 1992856348 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60294690) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: OR 8001) |
| Enumeration Date | 2007-01-14 |
| Last Update Date | 2012-10-31 |