| NPI | 1588243448 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 125Q00000X Oral Medicinist (Licence: WA DE61100565) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE61100565) |
| Enumeration Date | 2021-04-06 |
| Last Update Date | 2023-07-21 |