| NPI | 1104359959 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MATTHEW ELWOOD KOEPKE Member 304-904-7145 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: WV 4011) |
| Enumeration Date | 2017-04-09 |
| Last Update Date | 2017-04-09 |