| NPI | 1639736382 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: WA MD61570725) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WA DE61533860) |
| Enumeration Date | 2019-05-28 |
| Last Update Date | 2026-01-18 |