| NPI | 1215502125 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SANDY KROSLACK Credentialing Specialist 904-201-1428 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery |
| Additional Taxonomies | 1223P0106X Dentist, Oral and Maxillofacial Pathology |
| 1223G0001X Dentist, General Practice | |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery | |
| 1223X2210X Dentist, Orofacial Pain | |
| Enumeration Date | 2021-05-24 |
| Last Update Date | 2023-07-21 |