| NPI | 1801961636 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE00007572) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA DDS40679) |
| Enumeration Date | 2006-11-20 |
| Last Update Date | 2023-03-07 |