| NPI | 1396398673 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61215194) |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D11264) |
| 122300000X Dentist (Licence: SC 9454) | |
| 1223G0001X Dentist, General Practice (Licence: OR D11264) | |
| Enumeration Date | 2019-07-16 |
| Last Update Date | 2026-02-12 |