| NPI | 1134544075 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE 60551302) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DR60468203) |
| Enumeration Date | 2014-03-02 |
| Last Update Date | 2025-11-19 |