| NPI | 1609201508 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: WA DE60378589) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60378589) |
| Enumeration Date | 2013-09-10 |
| Last Update Date | 2026-08-02 |