Individual
CA CAO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1709 1ST ST S, WILLMAR, MN 56201-4488
(320) 437-8867
Mailing address
900 GOLDEN WHEEL PARK DR SPC 217, SAN JOSE, CA 95112-1265
(408) 893-9358
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
D15376
MN
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
06/27/2025
Last updated
08/07/2025
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