| NPI | 1023367083 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60600830) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA CA-32676) |
| 1223G0001X Dentist, General Practice (Licence: WA DE60600830) | |
| Enumeration Date | 2012-09-06 |
| Last Update Date | 2025-02-03 |