| NPI | 1851619795 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60124145) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: ID D4287) |
| Enumeration Date | 2010-05-16 |
| Last Update Date | 2020-04-07 |