| NPI | 1700503133 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ALEXIS PHILLIPS LYALL Owner Dentist 208-500-5437 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry |
| Additional Taxonomies | 261QD0000X Clinic/Center Dental |
| Enumeration Date | 2022-10-26 |
| Last Update Date | 2022-10-26 |