| NPI | 1699296962 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60607482) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA RR60534951) |
| Enumeration Date | 2017-06-27 |
| Last Update Date | 2021-03-17 |