| NPI | 1972961399 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE61344131) |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: AZ D00948) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-01-29 |
| Last Update Date | 2022-11-21 |