| NPI | 1871049767 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: GA DN015268) |
| Additional Taxonomies | 122300000X Dentist (Licence: GA DN015268) |
| 1223G0001X Dentist, General Practice (Licence: GA DN015268) | |
| Enumeration Date | 2016-08-30 |
| Last Update Date | 2020-04-02 |