| NPI | 1700438793 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: AZ D012788) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60967449) |
| 1223G0001X Dentist, General Practice (Licence: WA DE60967449) | |
| Enumeration Date | 2019-07-10 |
| Last Update Date | 2026-05-19 |