| NPI | 1134522535 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JERRY MICHAEL CARBONE Managing Member 208-917-2855 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center Dental (Licence: ID D3642EN) |
| Enumeration Date | 2014-09-30 |
| Last Update Date | 2014-09-30 |