| NPI | 1528509510 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 125K00000X Advanced Practice Dental Therapist (Licence: MN DT78) |
| Additional Taxonomies | 124Q00000X Dental Hygienist (Licence: MN H9909) |
| 125J00000X Dental Therapist (Licence: MN DT78) | |
| Enumeration Date | 2017-03-10 |
| Last Update Date | 2019-03-28 |