| NPI | 1104590504 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MARIBEL NEAONVER Credentialing Specialist 360-616-3138 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Additional Taxonomies | 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) |
| Enumeration Date | 2021-08-09 |
| Last Update Date | 2021-09-16 |