| NPI | 1255727996 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: MI 2901601249) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE 60654296) |
| Enumeration Date | 2015-04-09 |
| Last Update Date | 2022-08-26 |