| NPI | 1417170655 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | HOLLY MARIE PORTWOOD Manager 817-920-6936 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery |
| Additional Taxonomies | 1223P0106X Dentist, Oral and Maxillofacial Pathology |
| Enumeration Date | 2007-04-10 |
| Last Update Date | 2010-07-15 |