| NPI | 1679019681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: WA DE60745079) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AZ D011969) |
| 1223G0001X Dentist, General Practice (Licence: CA 101292) | |
| Enumeration Date | 2017-01-13 |
| Last Update Date | 2024-09-17 |