| NPI | 1558733410 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BLAKE CARSON KINGSBURY Owner 904-710-8011 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: NC 9534) |
| Additional Taxonomies | 122300000X Dentist (Licence: NC 8726) |
| 122300000X Dentist (Licence: NC 9309) | |
| Enumeration Date | 2015-10-30 |
| Last Update Date | 2015-10-30 |