| NPI | 1104057587 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D9404) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223G0001X Dentist, General Practice (Licence: WA DE 60140266) | |
| Enumeration Date | 2009-08-03 |
| Last Update Date | 2011-08-01 |