| NPI | 1922413467 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: WA DE61153482) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 9714) |
| Enumeration Date | 2014-06-24 |
| Last Update Date | 2023-01-06 |