| NPI | 1497332126 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: SC 10702) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE61295237) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-03-27 |
| Last Update Date | 2024-05-21 |