| NPI | 1639665383 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: WA DE60877925) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60877925) |
| Enumeration Date | 2018-07-05 |
| Last Update Date | 2019-10-24 |