| 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 |