| NPI | 1205816402 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: TX 21658) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE00010662) |
| Enumeration Date | 2006-01-23 |
| Last Update Date | 2023-03-07 |