| NPI | 1649825886 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MICHELLE JOHNSON Credentialing Specialists 509-315-8338 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery |
| Additional Taxonomies | 1223E0200X Dentist Endodontics |
| 1223P0300X Dentist Periodontics | |
| 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics | |
| Enumeration Date | 2019-08-05 |
| Last Update Date | 2019-09-12 |