| NPI | 1902161417 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60292929) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: ID D4439) |
| Enumeration Date | 2012-07-10 |
| Last Update Date | 2021-04-07 |