| NPI | 1508226317 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE 60659999) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA 60659999) |
| Enumeration Date | 2016-03-07 |
| Last Update Date | 2021-07-29 |