| NPI | 1760614481 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60400620) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: ID D-4236) |
| Enumeration Date | 2009-08-13 |
| Last Update Date | 2020-11-06 |