Individual
MICHELLE TA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DMD
Contact information
Practice address
912 GRAND AVE STE 202, SAN RAFAEL, CA 94901-3552
(408) 717-0888
Mailing address
77 TENNANT AVE, SAN JOSE, CA 95138-1851
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
DDS104671
CA
Other
Enumeration date
06/09/2020
Last updated
06/09/2020
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