| NPI | 1063934396 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: WA DE61490753) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 2952000557) |
| Enumeration Date | 2017-07-07 |
| Last Update Date | 2023-12-04 |