| NPI | 1356155808 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DEUW.DR.61663679) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 122300000X Dentist (Licence: SC DGD.11312.GD) | |
| Enumeration Date | 2025-02-05 |
| Last Update Date | 2026-03-15 |