| NPI | 1831578137 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE60655121) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: WA RR60560213) |
| Enumeration Date | 2015-05-20 |
| Last Update Date | 2016-06-06 |