| NPI | 1003194317 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KELLY GWYNNE MASON FERGUS Sole Mbr 870-336-3366 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics (Licence: AR 115) |
| Enumeration Date | 2011-08-03 |
| Last Update Date | 2011-08-03 |