| NPI | 1720292436 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: WA MD60495614) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WA DE60497405) |
| Enumeration Date | 2007-05-10 |
| Last Update Date | 2020-02-29 |