| NPI | 1265195614 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | AMANDA ANNE CLARK Director Of Credentialing 267-362-5938 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice |
| Enumeration Date | 2021-10-21 |
| Last Update Date | 2021-10-21 |