| NPI | 1790168623 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61005425) |
| Additional Taxonomies | 122300000X Dentist (Licence: KY 9591) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: KY 9591) | |
| Enumeration Date | 2015-07-09 |
| Last Update Date | 2022-08-11 |