| NPI | 1760923452 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MI 2901022545) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DEUW.DR.60736653) |
| Enumeration Date | 2017-03-14 |
| Last Update Date | 2020-04-13 |