| NPI | 1386211357 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE61434045) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO DEN.00204732) |
| Enumeration Date | 2021-06-08 |
| Last Update Date | 2025-06-24 |