| NPI | 1659044063 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN122398) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 13822) |
| 122300000X Dentist (Licence: SC 9972) | |
| Enumeration Date | 2021-07-30 |
| Last Update Date | 2026-03-05 |