| NPI | 1447874110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D012030) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE61062819) |
| Enumeration Date | 2020-05-29 |
| Last Update Date | 2024-10-15 |