| NPI | 1134637143 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 125K00000X Advanced Practice Dental Therapist (Licence: MN DT71) |
| Additional Taxonomies | 125J00000X Dental Therapist (Licence: MN DT71) |
| Enumeration Date | 2018-01-12 |
| Last Update Date | 2022-05-02 |