| NPI | 1750638334 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ROBERT GENE WAGONER Owner 570-814-3085 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: KY 7298) |
| Enumeration Date | 2012-08-13 |
| Last Update Date | 2012-08-13 |