| NPI | 1700255015 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60581724) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE60581724) |
| Enumeration Date | 2015-09-16 |
| Last Update Date | 2025-02-03 |