| NPI | 1497059166 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SHANNON NISSEN Owner 949-830-4101 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: CA 56349) |
| Enumeration Date | 2011-01-10 |
| Last Update Date | 2011-01-10 |