| NPI | 1164121448 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61618296) |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 39780) |
| 1223G0001X Dentist, General Practice (Licence: WA DE61618296) | |
| 1223G0001X Dentist, General Practice (Licence: TX 39780) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2023-02-27 |
| Last Update Date | 2025-04-14 |