| NPI | 1982618070 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60103984) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: IA 08337) |
| Enumeration Date | 2006-07-27 |
| Last Update Date | 2021-07-23 |