| NPI | 1578612925 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CHARLES MACON WALLACE Owner President 239-643-4746 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: FL DN14024) |
| Enumeration Date | 2007-01-08 |
| Last Update Date | 2010-09-29 |