| NPI | 1285675652 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: WA DE5767) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: OR D6001) |
| Enumeration Date | 2006-06-09 |
| Last Update Date | 2023-06-21 |