| NPI | 1063074250 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE61437579) |
| Additional Taxonomies | 122400000X Denturist (Licence: OR 10195475) |
| Enumeration Date | 2019-07-08 |
| Last Update Date | 2023-10-25 |