| NPI | 1821607060 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | LISA MARIE ANDERSON Owner 602-300-2384 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 122300000X Dentist |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies |
| Enumeration Date | 2020-07-23 |
| Last Update Date | 2020-07-23 |