| NPI | 1588365977 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: WA 61462922) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: MA 1) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2023-03-14 |
| Last Update Date | 2023-10-28 |