| NPI | 1114763729 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DENT.DE.70035415) |
| Additional Taxonomies | 122300000X Dentist (Licence: UT 14025093-9926) |
| Enumeration Date | 2024-07-02 |
| Last Update Date | 2025-12-20 |