Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | DDS101380 | CA |
NPI | 1063896587 |
---|---|
Provider Name | Laurita Siu |
First Address | Hesperia, CA 92345 |
Second Address | Las Vegas, NV 89106-4124 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/07/2015 |
Last Update Date | 06/09/2017 |