| NPI | 1790845808 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE61306850) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: PA ds036972) |
| 1223G0001X Dentist, General Practice (Licence: CA 55531) | |
| Enumeration Date | 2006-12-11 |
| Last Update Date | 2022-07-29 |