NPI | 1912394578 |
---|---|
Former Name | AUDREY MICHELLE RIESEN |
Entity Type | Individual |
Gender | Female |
Sole Proprietor ? | No |
Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: OR D10484) |
Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry (Licence: OR D10484) |
1223P0221X Dentist, Pediatric Dentistry (Licence: WA DE61168847) | |
Enumeration Date | 2015-04-22 |
Last Update Date | 2023-09-29 |