| NPI | 1760597157 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA 70118618) |
| Additional Taxonomies | 122300000X Dentist (Licence: VA 0401410048) |
| Enumeration Date | 2006-08-19 |
| Last Update Date | 2026-08-28 |