| NPI | 1467089318 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: CA 106731) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DR61067002) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-03-23 |
| Last Update Date | 2021-09-15 |