| NPI | 1407239965 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: WA DE61393867) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: KS 61160) |
| Enumeration Date | 2015-07-02 |
| Last Update Date | 2023-10-18 |