| NPI | 1699135087 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | HALEY WOOSTER Enrollment Specialist 984-251-8846 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Additional Taxonomies | 122300000X Dentist |
| Enumeration Date | 2016-02-29 |
| Last Update Date | 2025-09-10 |