| NPI | 1144884560 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SIMONE WILSON Director Of Credentialing & Enroll 848-326-8840 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Enumeration Date | 2019-05-01 |
| Last Update Date | 2023-05-02 |