| NPI | 1730472986 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223P0300X Dentist, Periodontics (Licence: WA DE 60567389) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223P0300X Dentist, Periodontics (Licence: CA 60645) | |
| 1223P0300X Dentist, Periodontics (Licence: OR D10180) | |
| Enumeration Date | 2011-05-20 |
| Last Update Date | 2015-07-12 |