| NPI | 1578869657 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA 60512673) |
| Additional Taxonomies | 122300000X Dentist (Licence: OK 6257) |
| 122300000X Dentist (Licence: CA 60143) | |
| Enumeration Date | 2011-02-07 |
| Last Update Date | 2022-07-21 |