| NPI | 1699349506 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: WA DE61405267) |
| 1223G0001X Dentist, General Practice (Licence: WA DE61405267) | |
| Enumeration Date | 2021-05-15 |
| Last Update Date | 2023-08-10 |