| NPI | 1831408178 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JUSTIN NEIL TEBBENKAMP Owner/President 540-961-3279 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: VA 0401412219) |
| Enumeration Date | 2010-10-05 |
| Last Update Date | 2010-10-05 |