| NPI | 1508247099 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60619915) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN21187) |
| Enumeration Date | 2015-06-10 |
| Last Update Date | 2022-12-20 |