| NPI | 1790964112 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA 10613) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA 10613) |
| Enumeration Date | 2007-11-01 |
| Last Update Date | 2022-03-24 |