| NPI | 1154714558 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DR60555137) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223G0001X Dentist, General Practice (Licence: WA DR60555137) | |
| Enumeration Date | 2015-03-09 |
| Last Update Date | 2015-07-13 |