| NPI | 1548990005 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN123111) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA DN1859553) |
| Enumeration Date | 2022-06-15 |
| Last Update Date | 2023-06-20 |