| NPI | 1023765393 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X2210X Dentist, Orofacial Pain (Licence: WA DE61333205) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE61333205) |
| Enumeration Date | 2022-03-07 |
| Last Update Date | 2025-05-13 |