| NPI | 1013360858 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | EDNA BUCKLE President 678-982-5136 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: MD 14775) |
| Additional Taxonomies | 261QD0000X Clinic/Center, Dental |
| Enumeration Date | 2016-07-17 |
| Last Update Date | 2023-02-15 |