| NPI | 1093160350 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | GEORGE J LOFTUS Member 208-660-4880 |
| Organization Subpart ? | No |
| Primary Taxonomy | 332BC3200X Durable Medical Equipment & Medical Supplies, Customized Equipment (Licence: ID 3019) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID 3019) |
| Enumeration Date | 2016-04-25 |
| Last Update Date | 2016-04-25 |