| NPI | 1538894779 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE61322146) | 
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: NM DB-2023-0234) | 
| Enumeration Date | 2022-07-21 | 
| Last Update Date | 2025-08-19 |