| NPI | 1487036901 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE60570949) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60570949) |
| Enumeration Date | 2015-06-20 |
| Last Update Date | 2025-01-29 |