| NPI | 1043659105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA 60707787) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA 62454) |
| Enumeration Date | 2013-06-21 |
| Last Update Date | 2022-07-21 |