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Individual provider · General Practice Dentistry · Lake Forest, CA

NPI
1154298974
Type
Individual (Type 1)
Primary specialty
General Practice Dentistry (Dentist)
Specialty group
Dental Providers
Taxonomy code
1223G0001X
License number
112255 (CA)
Sex
Male
Sole proprietor
Yes
Enumerated
2025-10-17
Last updated
2025-10-17
Practice location
1533 Viejo Ridge Dr S
Lake Forest, CA 92610-3026
(630) 660-7903

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