| NPI | 1003357468 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | HEATHER KRAUSHAAR Provider Relations Rep 315-454-6000 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: MO 2015041029) |
| Enumeration Date | 2017-03-17 |
| Last Update Date | 2017-03-17 |