| NPI | 1790355121 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE61518860) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: AZ D011081) |
| Enumeration Date | 2021-06-28 |
| Last Update Date | 2025-05-23 |