| NPI | 1043728827 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KAYLLA RUSSELL Admin Assistant 360-672-4168 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: WA DE60651466) |
| Enumeration Date | 2018-01-16 |
| Last Update Date | 2018-06-18 |