| NPI | 1699377952 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61215060) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 36860) |
| Enumeration Date | 2020-11-12 |
| Last Update Date | 2022-07-07 |