| NPI | 1437523776 |
|---|---|
| Doing Business As | INNOVATIVE DENTISTRY AT SOUTH LAKE UNION |
| Entity Type | Organization |
| Authorized Contact | CHELSEA M NAGEL Credentialing Manager 360-701-2002 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental |
| Enumeration Date | 2015-11-24 |
| Last Update Date | 2015-11-24 |