| NPI | 1871215806 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61592586) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 108020) |
| Enumeration Date | 2022-09-15 |
| Last Update Date | 2024-10-03 |