| NPI | 1972804037 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA 60483705) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: OK 6250) |
| 1223G0001X Dentist, General Practice (Licence: CA 59574) | |
| Enumeration Date | 2010-11-05 |
| Last Update Date | 2024-01-18 |