| NPI | 1942581749 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: ID D-4401) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE 60230317) |
| Enumeration Date | 2011-09-07 |
| Last Update Date | 2025-12-31 |