| NPI | 1457760654 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TRENT PRYOR Member 208-329-4580 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry (Licence: UT 8669834-9923) |
| Enumeration Date | 2014-08-13 |
| Last Update Date | 2014-08-13 |