| NPI | 1407694631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DENT.DE.70107966) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CT 14176) |
| Enumeration Date | 2024-07-20 |
| Last Update Date | 2026-09-24 |