| NPI | 1861841918 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: AZ 10161) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 1223P0221X Dentist, Pediatric Dentistry (Licence: WA 60796314) | |
| Enumeration Date | 2016-06-09 |
| Last Update Date | 2018-10-23 |