| NPI | 1174664460 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KELLY JOHANNA WAGGENER President 707-538-3325 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223E0200X Dentist, Endodontics |
| Additional Taxonomies | 1223G0001X Dentist, General Practice |
| 1223P0300X Dentist, Periodontics | |
| Enumeration Date | 2007-02-09 |
| Last Update Date | 2020-08-22 |