| NPI | 1538391040 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60103956) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE60103956) |
| Enumeration Date | 2009-08-17 |
| Last Update Date | 2022-08-04 |