| NPI | 1750840112 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KIMBERLY VANCAMP Credentialing & Enrollment Manager 470-337-5175 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental |
| Enumeration Date | 2019-03-15 |
| Last Update Date | 2024-12-12 |