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 |