| NPI | 1114133113 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 124Q00000X Dental Hygienist (Licence: CA 31862) |
| Additional Taxonomies | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| Enumeration Date | 2007-05-15 |
| Last Update Date | 2022-11-07 |