| NPI | 1700272663 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: WA DE60749890) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223G0001X Dentist General Practice (Licence: CA DDS100564) | |
| Enumeration Date | 2015-04-07 |
| Last Update Date | 2021-10-28 |