| NPI | 1487887972 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE 60106594) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60106594) |
| Enumeration Date | 2009-08-31 |
| Last Update Date | 2025-11-21 |