| NPI | 1053495853 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA 60535842) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO Den.00206446) |
| 122300000X Dentist (Licence: AZ D011709) | |
| Enumeration Date | 2006-10-25 |
| Last Update Date | 2025-10-22 |