| NPI | 1356874507 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CHARLES R FANA Member 912-352-3955 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental (Licence: GA DN011627) |
| Additional Taxonomies | 261QD0000X Clinic/Center, Dental (Licence: SC 3563) |
| Enumeration Date | 2017-04-05 |
| Last Update Date | 2017-04-05 |