| NPI | 1205114162 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE60802224) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID D4886) |
| Enumeration Date | 2011-07-26 |
| Last Update Date | 2026-08-05 |