| NPI | 1104606664 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | NICK SUNDIAM Credentialing Manager 719-300-5933 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery |
| Enumeration Date | 2023-10-03 |
| Last Update Date | 2023-10-03 |