| NPI | 1053892406 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA 60682750) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA 60682750) |
| Enumeration Date | 2018-08-23 |
| Last Update Date | 2018-08-23 |