NPI | 1285295022 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: WA DE60886789) |
Additional Taxonomies | 122300000X Dentist (Licence: WA DE60886789) |
Enumeration Date | 2019-06-24 |
Last Update Date | 2023-03-10 |