| NPI | 1053083295 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE.61153474) |
| Additional Taxonomies | 125Q00000X Oral Medicinist (Licence: WA DENT.DE.61153474) |
| Enumeration Date | 2021-10-05 |
| Last Update Date | 2022-07-11 |