| NPI | 1801181250 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WI 6704-15) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: WI 6704-15) |
| Enumeration Date | 2011-06-14 |
| Last Update Date | 2016-11-30 |