| NPI | 1194202051 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: NM DB-2023-0212) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60874699) |
| Enumeration Date | 2018-07-24 |
| Last Update Date | 2023-12-14 |