| NPI | 1194458935 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61322595) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: LA 7817) |
| Enumeration Date | 2022-07-08 |
| Last Update Date | 2026-06-18 |