| NPI | 1053495853 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA 60535842) |
| Additional Taxonomies | 122300000X Dentist (Licence: AZ D011709) |
| Enumeration Date | 2006-10-25 |
| Last Update Date | 2023-05-03 |