| NPI | 1538697974 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: OR D10682) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE61315076) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-05-30 |
| Last Update Date | 2022-09-06 |