| NPI | 1154843258 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA 61044416) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID D-4864) |
| Enumeration Date | 2017-07-10 |
| Last Update Date | 2025-01-29 |