| NPI | 1023451655 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: WA MD60918839) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WA DE61017384) |
| Enumeration Date | 2013-04-13 |
| Last Update Date | 2022-09-30 |