| NPI | 1407359334 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60894468) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DR60850394) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-03-16 |
| Last Update Date | 2025-05-14 |