| NPI | 1023693660 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61256641) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DR61162279) |
| Enumeration Date | 2021-03-15 |
| Last Update Date | 2022-07-12 |