| NPI | 1790704138 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE00007397) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA 07397) |
| Enumeration Date | 2006-07-18 |
| Last Update Date | 2021-01-04 |