| NPI | 1629345558 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60475231) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: TX 0) |
| Enumeration Date | 2011-11-21 |
| Last Update Date | 2025-10-23 |