| NPI | 1821439324 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61337518) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: CT 390200000) |
| Enumeration Date | 2013-07-12 |
| Last Update Date | 2023-10-05 |