| NPI | 1164836334 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 125K00000X Advanced Practice Dental Therapist (Licence: MN DT45) |
| Additional Taxonomies | 125J00000X Dental Therapist (Licence: MN DT45) |
| Enumeration Date | 2014-06-16 |
| Last Update Date | 2022-02-08 |