| NPI | 1568130409 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61211995) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE61211995) |
| Enumeration Date | 2021-09-03 |
| Last Update Date | 2025-02-03 |