| NPI | 1699551309 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SHERRIE EDMONDSON Sr Manager, L&C 629-999-5014 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice |
| Additional Taxonomies | 122300000X Dentist |
| 1223P0221X Dentist Pediatric Dentistry | |
| Enumeration Date | 2023-09-07 |
| Last Update Date | 2023-09-07 |