| NPI | 1598318255 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE61311634) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 104115) |
| Enumeration Date | 2019-07-22 |
| Last Update Date | 2022-11-21 |