| NPI | 1033751698 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CATHERINE M JENSEN Provider Relations Speicalist 800-544-2345 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Enumeration Date | 2019-10-15 |
| Last Update Date | 2019-10-15 |