| NPI | 1356781496 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: OR D10408) |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics (Licence: WA 60669129) |
| Enumeration Date | 2013-07-03 |
| Last Update Date | 2021-11-22 |