| NPI | 1558869917 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | WALLACE CARRILLO-MEDINA President 336-629-3112 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental (Licence: NC 9900) |
| Additional Taxonomies | 1223X2210X Dentist, Orofacial Pain |
| Enumeration Date | 2018-01-30 |
| Last Update Date | 2021-02-24 |