| NPI | 1487802096 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TRACY VAN DYKE Office Manager 208-237-3330 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: ID D-3206-OR) |
| Enumeration Date | 2008-09-08 |
| Last Update Date | 2008-09-08 |