# NPI 1710017736

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- **Entity:** Individual
- **Status:** Inactive

## Provider details

- **NPI number:** 1710017736

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | 4664 | WA | Yes |

## Other

- **Enumeration date:** —
- **Last updated:** —

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 4664 | DENTAL LICENCE | WA |