| NPI | 1124104732 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE00005742) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE00005742) |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: WA DE00005742) | |
| Enumeration Date | 2006-10-27 |
| Last Update Date | 2025-02-24 |