| NPI | 1750802104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61070798) |
| Additional Taxonomies | 122300000X Dentist (Licence: AK 124115) |
| Enumeration Date | 2017-07-06 |
| Last Update Date | 2026-01-10 |