| NPI | 1821451428 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | IVONNE TELLEZ Enrollment Team Lead 888-988-4066 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental |
| Additional Taxonomies | 1223G0001X Dentist, General Practice |
| Enumeration Date | 2016-03-31 |
| Last Update Date | 2021-10-15 |