| NPI | 1235621756 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA 61030599) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OR D10989) |
| 1223G0001X Dentist, General Practice (Licence: WI 1001842-15) | |
| Enumeration Date | 2018-05-31 |
| Last Update Date | 2022-07-18 |