| NPI | 1477081701 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: TX 35561) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WA 60840011) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-05-31 |
| Last Update Date | 2022-07-21 |