| NPI | 1982097457 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE.60659835) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN29803) |
| Enumeration Date | 2015-03-09 |
| Last Update Date | 2025-09-05 |