| NPI | 1013104892 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | VICKIE ALVEY Credentialing Coordinator 270-783-0064 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery |
| Additional Taxonomies | 1223P0106X Dentist, Oral and Maxillofacial Pathology |
| Enumeration Date | 2007-09-26 |
| Last Update Date | 2021-09-21 |