Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 52695 | CA |
NPI | 1003153461 |
---|---|
Provider Name | Mrs. Edita Vasiliauskas |
First Address | Santa Rosa, CA 95403-4175 |
Second Address | Santa Rosa, CA 95403-4175 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2013 |
Last Update Date | 04/01/2013 |