| NPI | 1417269200 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: WA DE60277222) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE 60277222) |
| Enumeration Date | 2010-07-08 |
| Last Update Date | 2022-01-13 |