| NPI | 1043408792 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: GA DN015157) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: GA PT9110) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2007-10-09 |
| Last Update Date | 2016-08-09 |