| NPI | 1659455913 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 175T00000X Peer Specialist |
| Additional Taxonomies | 122300000X Dentist (Licence: OR D10407) |
| 1223G0001X Dentist, General Practice (Licence: OK 4747) | |
| 1223G0001X Dentist, General Practice (Licence: WA DE8341) | |
| Enumeration Date | 2006-10-24 |
| Last Update Date | 2022-03-24 |