| NPI | 1043464035 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 125J00000X Dental Therapist (Licence: MN DT73) |
| Additional Taxonomies | 124Q00000X Dental Hygienist (Licence: MN H6853) |
| Enumeration Date | 2008-11-04 |
| Last Update Date | 2019-06-03 |