| NPI | 1083084404 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN122806) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 65136) |
| 122300000X Dentist (Licence: WA 60793892) | |
| Enumeration Date | 2015-09-28 |
| Last Update Date | 2022-10-01 |