| NPI | 1710468228 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN124057) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA DDS111702) |
| 1223G0001X Dentist, General Practice (Licence: TN 11443) | |
| 1223G0001X Dentist, General Practice (Licence: WA DE60862683) | |
| Enumeration Date | 2018-08-23 |
| Last Update Date | 2026-01-23 |