| NPI | 1669782066 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MD 14714) |
| Additional Taxonomies | 122300000X Dentist (Licence: LA D6133) |
| 122300000X Dentist (Licence: WA DE61389604) | |
| 1223G0001X Dentist, General Practice (Licence: WA DE61389604) | |
| Enumeration Date | 2010-10-19 |
| Last Update Date | 2025-02-20 |