| NPI | 1770828246 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 126800000X Dental Assistant (Licence: WA D160053453) |
| Additional Taxonomies | 126800000X Dental Assistant (Licence: OR 116505) |
| Enumeration Date | 2012-12-10 |
| Last Update Date | 2012-12-10 |