| NPI | 1093133696 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TROY RICHARD PETERSEN President 7001-772-7379 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery |
| Enumeration Date | 2014-04-01 |
| Last Update Date | 2014-05-19 |