| NPI | 1114314747 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MARVIN BLANE JACKSON President 801-210-2568 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center Dental (Licence: UT 6605138) |
| Enumeration Date | 2015-04-21 |
| Last Update Date | 2015-04-21 |