| NPI | 1255873345 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WA DE61424421) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA DDS100351) |
| Enumeration Date | 2016-11-07 |
| Last Update Date | 2024-01-26 |