| NPI | 1386903813 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA 00007524) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID D3794) |
| Enumeration Date | 2012-05-03 |
| Last Update Date | 2025-04-14 |