| NPI | 1184864027 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60338396) |
| Additional Taxonomies | 122300000X Dentist (Licence: MP 0102) |
| 122300000X Dentist (Licence: OR D8320) | |
| Enumeration Date | 2009-03-05 |
| Last Update Date | 2024-01-15 |