| NPI | 1821738675 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61401506) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID D-5488) |
| Enumeration Date | 2022-03-30 |
| Last Update Date | 2023-07-06 |