| NPI | 1013535566 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61085674) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA TP61087052) |
| 1223G0001X Dentist, General Practice (Licence: WA DE61085674) | |
| Enumeration Date | 2020-07-10 |
| Last Update Date | 2024-07-25 |