| NPI | 1720058746 |
|---|---|
| Former Name | MICHELLE DIANE PETERSEN |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: WA DE00010510) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: ID D-3457) |
| Enumeration Date | 2006-01-23 |
| Last Update Date | 2021-11-29 |