| NPI | 1356481568 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MARTY SHANE TRAYLOR Registered Agent Member 270-993-2841 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Additional Taxonomies | 152W00000X Optometrist |
| 213E00000X Podiatrist | |
| Enumeration Date | 2007-02-07 |
| Last Update Date | 2020-08-22 |