| NPI | 1700579216 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D012031) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE61435139) |
| Enumeration Date | 2023-05-31 |
| Last Update Date | 2024-01-30 |