| NPI | 1073045027 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: WA DE60882689) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA DDS101029) |
| Enumeration Date | 2017-03-29 |
| Last Update Date | 2022-06-08 |