| NPI | 1619591047 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA 61060243) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA 61060243) |
| Enumeration Date | 2020-06-01 |
| Last Update Date | 2024-08-11 |