| NPI | 1831545102 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MARK A TALL Owner 208-356-5601 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: ID D4747) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: ID D2018) |
| Enumeration Date | 2016-05-05 |
| Last Update Date | 2016-05-05 |