| NPI | 1346804994 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 103833) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE60936281) |
| Enumeration Date | 2019-04-30 |
| Last Update Date | 2024-05-07 |