| NPI | 1366950594 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WA 61358923) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D10743) |
| Enumeration Date | 2018-01-22 |
| Last Update Date | 2023-05-15 |