| NPI | 1588086359 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 125J00000X Dental Therapist (Licence: MN D180) |
| Additional Taxonomies | 124Q00000X Dental Hygienist (Licence: VA 0402206182) |
| 125K00000X Advanced Practice Dental Therapist (Licence: MN D180) | |
| Enumeration Date | 2014-01-14 |
| Last Update Date | 2025-06-17 |