| NPI | 1013323518 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60570245) |
| Additional Taxonomies | 122300000X Dentist (Licence: CT 011205) |
| Enumeration Date | 2014-07-03 |
| Last Update Date | 2026-04-27 |