| NPI | 1063972594 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61081543) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: WA DR60951032) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-03-21 |
| Last Update Date | 2020-09-03 |