| NPI | 1558137604 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SHAUNDA ELYSE KELLY CEO 386-837-1236 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QS0112X Clinic/Center, Oral and Maxillofacial Surgery |
| Enumeration Date | 2023-11-29 |
| Last Update Date | 2023-11-29 |