| NPI | 1780497396 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KELLIE J ELLISON Administration 757-548-1712 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QS0112X Clinic/Center, Oral and Maxillofacial Surgery |
| Enumeration Date | 2025-01-28 |
| Last Update Date | 2025-01-28 |