| NPI | 1245518059 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: WA DE60446726) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60446726) |
| 122300000X Dentist (Licence: OR D9994) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2011-07-27 |
| Last Update Date | 2018-04-19 |