| NPI | 1043520042 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MARK M WIDLOSKI Owner 865-983-8630 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TN 4711) |
| Enumeration Date | 2010-10-12 |
| Last Update Date | 2010-11-18 |