| NPI | 1255339297 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KACI B. JENSEN Owner 208-791-4926 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: ID D-4034) |
| Additional Taxonomies | 261QD0000X Clinic/Center Dental (Licence: MO 2000159748) |
| Enumeration Date | 2005-07-13 |
| Last Update Date | 2011-03-07 |