| NPI | 1780812313 |
|---|---|
| Former Name | JACQUELINE LEAH ILLUMINATE |
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: SC 9522) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: SC 9522) |
| Enumeration Date | 2009-06-22 |
| Last Update Date | 2024-05-08 |