| NPI | 1902152887 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60291757) |
| Additional Taxonomies | 122300000X Dentist (Licence: IA DDS-09972) |
| Enumeration Date | 2012-07-30 |
| Last Update Date | 2023-11-28 |