| NPI | 1720725484 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61477776) |
| Additional Taxonomies | 122300000X Dentist (Licence: CO Pending) |
| Enumeration Date | 2022-05-15 |
| Last Update Date | 2025-06-04 |