Facts
- Status
- A
- Credential
- DDS
- Type
- Individual
- Enumeration date
- 2020-08-20
- Last updated
- 2020-08-20
Licenses
- License CA
- 105340
- License CA
- 105340
Location
- Practice location
- 1108 S MAIN AVE
- City
- FALLBROOK CA
- Postal code
- 920283325
- Phone
- 760-728-2261
Medicare
- PECOS
- No PECOS enrollment row matched this NPI.
LEIE
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Nearby
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Removal request
Public data from NPPES and CMS. Not a credentialing determination.