| NPI | 1396317400 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61404678) |
| Additional Taxonomies | 122300000X Dentist (Licence: WI 1002647) |
| 1223G0001X Dentist, General Practice (Licence: ID D-5368) | |
| Enumeration Date | 2021-07-16 |
| Last Update Date | 2026-05-29 |