| NPI | 1548628175 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA DE60660643) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: WA RR 60559973) |
| Enumeration Date | 2016-02-10 |
| Last Update Date | 2016-07-13 |