| NPI | 1568854875 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MARCUS KENNETH RANDALL Owner 423-877-3848 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental (Licence: TN 9947) |
| Additional Taxonomies | 261QD0000X Clinic/Center, Dental (Licence: TN 3483) |
| Enumeration Date | 2015-02-23 |
| Last Update Date | 2015-02-23 |