| NPI | 1053799080 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JENELL STUMP Manager, Licensing & Credentialing 629-999-5006 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Enumeration Date | 2015-05-11 |
| Last Update Date | 2018-05-07 |