| NPI | 1578511572 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JEAN DIANE SOUTHWORTH Business Administrator 218-727-8994 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery |
| Enumeration Date | 2006-05-04 |
| Last Update Date | 2020-08-22 |