| NPI | 1265176432 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: WA DR61678626) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA DDS110071) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-04-25 |
| Last Update Date | 2025-07-01 |