| NPI | 1548667173 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ELISE H. LEE Office Manager 662-513-0055 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: MS 3577-10) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: MS 3733-14) |
| Enumeration Date | 2014-11-25 |
| Last Update Date | 2014-11-25 |