| NPI | 1699495580 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CHAD HENDRICKS Credentialing 612-859-0444 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery |
| Additional Taxonomies | 1223G0001X Dentist General Practice |
| Enumeration Date | 2022-08-31 |
| Last Update Date | 2022-08-31 |