| NPI | 1598125643 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: WA DR60648241) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DR60648241) |
| Enumeration Date | 2016-03-02 |
| Last Update Date | 2019-05-30 |