| NPI | 1891234050 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208600000X Surgery (Licence: AL 46766) |
| Additional Taxonomies | 122300000X Dentist (Licence: WA DE60853764) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-02-20 |
| Last Update Date | 2024-01-15 |