| NPI | 1104167055 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | RYAN GREEN President 325-232-8939 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 24237) |
| Additional Taxonomies | 174400000X Specialist (Licence: TX N4439) |
| 208600000X Surgery (Licence: TX N4439) | |
| Enumeration Date | 2013-03-01 |
| Last Update Date | 2013-03-01 |