| NPI | 1790187128 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | HALEY WOOSTER Credentialing Specialist 712-744-4529 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401413867) |
| Enumeration Date | 2014-09-17 |
| Last Update Date | 2014-09-17 |