| NPI | 1316635600 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DENT.DE.70083703) |
| Additional Taxonomies | 122300000X Dentist (Licence: CA 109444) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2023-04-26 |
| Last Update Date | 2026-06-03 |