| NPI | 1992234173 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60932123) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901022303) |
| Enumeration Date | 2017-06-09 |
| Last Update Date | 2023-02-11 |