| NPI | 1639426836 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LARRY M BLACK Owner 229-263-8700 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental (Licence: GA DN012932) |
| Additional Taxonomies | 261QD0000X Clinic/Center, Dental (Licence: GA DNSC000233) |
| Enumeration Date | 2012-08-07 |
| Last Update Date | 2012-08-07 |