| NPI | 1063234946 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CHRISTINE BARBER Provider Enrollment Team Lead 315-454-6000 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Enumeration Date | 2024-10-30 |
| Last Update Date | 2024-10-30 |