| NPI | 1780189084 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: GA DN015739) |
| Additional Taxonomies | 122300000X Dentist (Licence: GA DN015739) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2018-03-28 |
| Last Update Date | 2018-10-13 |