| NPI | 1316612518 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: WA DR61476522) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: CA DDS106715) |
| 122300000X Dentist (Licence: CA DDS106715) | |
| Enumeration Date | 2021-08-11 |
| Last Update Date | 2024-03-29 |