| NPI | 1164589834 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 110878) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA 9030) |
| Enumeration Date | 2007-01-02 |
| Last Update Date | 2025-01-15 |