| NPI | 1871155267 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61087994) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CA DDS105517) |
| Enumeration Date | 2019-07-05 |
| Last Update Date | 2024-05-23 |