| NPI | 1659671824 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | STEVEN M. WAGNER Managing Director 915-594-3584 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 0012562) |
| Additional Taxonomies | 122300000X Dentist |
| 1223P0221X Dentist, Pediatric Dentistry | |
| Enumeration Date | 2010-10-22 |
| Last Update Date | 2019-06-17 |