| NPI | 1588230403 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: ID D-5579) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE61164746) |
| Enumeration Date | 2021-06-01 |
| Last Update Date | 2025-10-07 |