| NPI | 1790127512 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LESLIE SEPANEK Credentialing Specialist 502-813-4415 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist |
| Additional Taxonomies | 124Q00000X Dental Hygienist |
| Enumeration Date | 2013-07-22 |
| Last Update Date | 2016-12-09 |