| NPI | 1083073522 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D10432) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: WA RR60578878) |
| Enumeration Date | 2016-02-12 |
| Last Update Date | 2023-04-10 |