| NPI | 1316957442 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WA DE 60272622) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2006-08-09 |
| Last Update Date | 2023-04-05 |