Individual
ERISA SAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DMD
Contact information
Practice address
10720 W INDIAN SCHOOL RD STE 55, PHOENIX, AZ 85037-5724
(623) 246-7051
Mailing address
5901 W BEHREND DR APT 1113, GLENDALE, AZ 85308-6941
(949) 702-2068
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
D010677
AZ
Other
Enumeration date
06/05/2020
Last updated
06/05/2020
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