| NPI | 1265018204 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61309778) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: WA DE61309778) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-03-21 |
| Last Update Date | 2023-04-12 |