| NPI | 1831507482 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE 60475182) |
| Additional Taxonomies | 122300000X Dentist (Licence: NV 7124) |
| Enumeration Date | 2014-07-28 |
| Last Update Date | 2022-03-23 |