| NPI | 1104630748 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | URSULA SHANERRA ROSA Credentialing & Privileging Manager 706-922-0600 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental |
| Enumeration Date | 2025-02-04 |
| Last Update Date | 2025-07-28 |