| NPI | 1518267640 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: DC DEN1001056) |
| Additional Taxonomies | 122300000X Dentist (Licence: FL DN19524) |
| 1223G0001X Dentist, General Practice (Licence: DC DEN1001056) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2010-10-22 |
| Last Update Date | 2024-02-01 |