| NPI | 1770987703 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60610618) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA RR60481192) |
| 122300000X Dentist (Licence: CA 64901) | |
| Enumeration Date | 2014-10-20 |
| Last Update Date | 2020-03-01 |