| NPI | 1265935902 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | GREGG ANDREW WILSON Dentist/CEO 208-906-0501 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental (Licence: ID D35345) |
| Enumeration Date | 2018-03-08 |
| Last Update Date | 2018-03-08 |