| NPI | 1114536653 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61085473) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO 204553) |
| Enumeration Date | 2020-07-30 |
| Last Update Date | 2024-04-11 |