| NPI | 1558626929 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: GA DN015981) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: WA DE60459114) |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: OR D10030) | |
| Enumeration Date | 2012-07-11 |
| Last Update Date | 2021-01-07 |