| NPI | 1356870950 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | GLENN TERRELL GREEN Owner 208-406-1777 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 32346) |
| Enumeration Date | 2017-06-07 |
| Last Update Date | 2024-02-28 |