| NPI | 1174717524 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WA DE60426234) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: ID d4095) |
| Enumeration Date | 2007-08-29 |
| Last Update Date | 2020-12-16 |