| NPI | 1952794562 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401418470) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DR60555120) |
| Enumeration Date | 2015-03-07 |
| Last Update Date | 2023-06-14 |