| NPI | 1619791001 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KIA WILLIAMS Provider Enrollment Team Lead 315-454-6000 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Enumeration Date | 2024-11-12 |
| Last Update Date | 2024-11-12 |