| NPI | 1457857104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: LA 6878) |
| Additional Taxonomies | 122300000X Dentist (Licence: LA 6878) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-04-02 |
| Last Update Date | 2020-05-05 |