| NPI | 1053315952 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN012805) |
| Additional Taxonomies | 122300000X Dentist (Licence: PA DS028119L) |
| Enumeration Date | 2005-06-08 |
| Last Update Date | 2022-07-21 |