| NPI | 1700307220 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MARY CLEMENTS Practice Manager 863-832-0028 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery | |
| Enumeration Date | 2017-07-06 |
| Last Update Date | 2022-07-21 |