| NPI | 1851779888 |
|---|---|
| Other Name | KENTUCKY04 |
| Entity Type | Organization |
| Authorized Contact | MANDY HOLLAND Credentialing Manager 256-504-3326 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Enumeration Date | 2015-05-11 |
| Last Update Date | 2015-05-11 |