| NPI | 1093282972 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61250032) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN23802) |
| Enumeration Date | 2018-10-29 |
| Last Update Date | 2023-05-30 |