Individual
EDA WU
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
17117 DETROIT AVE, CLEVELAND, OH 44107-3622
(216) 221-0300
Mailing address
17117 DETROIT AVE, CLEVELAND, OH 44107-3622
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
133160509923
UT
1223G0001X
General Practice Dentistry
Primary
30.027710
OH
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
04/09/2022
Last updated
04/18/2026
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