| NPI | 1184251423 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CA 107388) |
| Additional Taxonomies | 204E00000X Oral & Maxillofacial Surgery (Licence: WA DR61068962) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-03-25 |
| Last Update Date | 2023-01-05 |