| NPI | 1245521012 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | GARY L REVERCOMB Dentist 315-682-8400 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: NY 030581) |
| Enumeration Date | 2011-04-27 |
| Last Update Date | 2011-04-27 |