| NPI | 1740834852 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 105681) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60975999) |
| Enumeration Date | 2019-07-26 |
| Last Update Date | 2021-10-15 |