| NPI | 1659536217 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60033879) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MO 2020041753) |
| Enumeration Date | 2008-07-23 |
| Last Update Date | 2021-03-08 |