| NPI | 1558544114 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WA DE 00011119) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE00011119) |
| Enumeration Date | 2007-12-06 |
| Last Update Date | 2020-09-08 |