| NPI | 1316095904 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | VAN PHI LE Credentialing Contracts Manager 267-575-2321 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: DE g1-0000909) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: DE g1-0000893) |
| Enumeration Date | 2007-01-08 |
| Last Update Date | 2021-02-10 |