| NPI | 1699016956 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401414392) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 122300000X Dentist (Licence: WA DR60361086) | |
| Enumeration Date | 2013-03-12 |
| Last Update Date | 2016-03-23 |