Individual
KERISA SUE ELLOWAY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
D.D.S.
Contact information
Practice address
1730 MAIN ST, SUITE A, FORTUNA, CA 95540-2451
(707) 725-1303
(707) 725-1358
Mailing address
1730 MAIN ST STE A, FORTUNA, CA 95540-2451
(707) 725-1303
(707) 725-1358
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
47254
CA
Other
Enumeration date
03/08/2007
Last updated
07/08/2007
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