| NPI | 1053956466 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | EBONIE GONZALES Credentialing Manager 505-850-3769 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics |
| Enumeration Date | 2019-11-08 |
| Last Update Date | 2022-05-23 |