| NPI | 1639552110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CO DEN.00203532) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE60578286) |
| Enumeration Date | 2015-07-02 |
| Last Update Date | 2023-02-21 |