| NPI | 1275123481 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: WA DR61427419) |
| Additional Taxonomies | 122300000X Dentist (Licence: NE 7671) |
| Enumeration Date | 2021-01-21 |
| Last Update Date | 2024-04-03 |