| NPI | 1518543222 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61187214) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY D-00172) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-03-23 |
| Last Update Date | 2026-07-02 |