| NPI | 1154495653 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60986364) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE60986364) |
| 1223G0001X Dentist, General Practice (Licence: CA 37412) | |
| Enumeration Date | 2006-11-17 |
| Last Update Date | 2023-02-17 |