| NPI | 1689025975 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D10833) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60665299) |
| Enumeration Date | 2016-06-28 |
| Last Update Date | 2021-02-21 |