| NPI | 1124568043 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TIFFANY LORICK Credentialing Specialist 704-806-3632 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: NV S681) |
| Enumeration Date | 2017-02-24 |
| Last Update Date | 2023-02-20 |