| NPI | 1891090833 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: AZ D011263) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60198986) |
| Enumeration Date | 2011-01-24 |
| Last Update Date | 2023-03-31 |