| NPI | 1770984551 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 35043) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60367261) |
| Enumeration Date | 2014-09-11 |
| Last Update Date | 2021-07-13 |