| NPI | 1558626879 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE60289450) |
| Additional Taxonomies | 1223E0200X Dentist, Endodontics (Licence: UT 10424103-9926) |
| Enumeration Date | 2012-07-12 |
| Last Update Date | 2026-07-06 |