| NPI | 1629950399 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DENT.DE.70137733) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA 111986) |
| Enumeration Date | 2025-07-23 |
| Last Update Date | 2026-06-28 |