| NPI | 1003961061 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JACOB WARNER Credentialing Manager 801-691-1701 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: CO 104471) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: CO 6035) |
| 1223G0001X Dentist, General Practice (Licence: CO 6716) | |
| Enumeration Date | 2007-01-23 |
| Last Update Date | 2021-07-02 |