| NPI | 1063157105 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MARK A TALL Owner 208-701-2720 |
| Organization Subpart ? | No |
| Primary Taxonomy | 332BC3200X Durable Medical Equipment & Medical Supplies, Customized Equipment |
| Additional Taxonomies | 122300000X Dentist |
| Enumeration Date | 2022-05-03 |
| Last Update Date | 2023-06-21 |