| NPI | 1316617491 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 125J00000X Dental Therapist (Licence: MN DT130) |
| Additional Taxonomies | 124Q00000X Dental Hygienist (Licence: MN H10783) |
| Enumeration Date | 2021-09-20 |
| Last Update Date | 2021-09-20 |