| NPI | 1558097709 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901602893) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DENT.DE.70040063) |
| Enumeration Date | 2022-07-29 |
| Last Update Date | 2026-06-28 |