| NPI | 1811188857 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 23652) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE00010979) |
| 1223G0001X Dentist, General Practice (Licence: MA 21811) | |
| Enumeration Date | 2007-08-06 |
| Last Update Date | 2026-01-11 |