| NPI | 1467908814 |
|---|---|
| Former Name | KELLY LAUREN VAN WAGENEN |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CT 14245) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 10574) |
| 122300000X Dentist (Licence: NC 151098) | |
| Enumeration Date | 2016-08-26 |
| Last Update Date | 2025-02-25 |