| NPI | 1093483612 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D12013) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE61178185) |
| Enumeration Date | 2021-08-30 |
| Last Update Date | 2024-07-31 |