| NPI | 1760503627 |
|---|---|
| Doing Business As | SAME AS ABOVE |
| Entity Type | Organization |
| Authorized Contact | SHERRIE EDMONDSON Manager, Licensing & Credentialing 629-999-5014 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry |
| Enumeration Date | 2007-04-02 |
| Last Update Date | 2021-12-31 |