| NPI | 1689304602 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: IL 019.033605) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE61427701) |
| Enumeration Date | 2022-06-13 |
| Last Update Date | 2023-05-16 |