| NPI | 1740476993 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SHANE1 RYAN COSTA Owner 804-690-2042 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: VA 0401410911) |
| Enumeration Date | 2007-09-21 |
| Last Update Date | 2007-09-21 |