| NPI | 1699220863 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: AZ D009991) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60682826) |
| 122300000X Dentist (Licence: AZ D009991) | |
| 122300000X Dentist (Licence: OR D10533) | |
| Enumeration Date | 2016-08-17 |
| Last Update Date | 2019-02-01 |