| NPI | 1437893005 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE6132122) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA DE61302122) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: WA DE61302122) | |
| Enumeration Date | 2022-04-20 |
| Last Update Date | 2023-08-07 |