| NPI | 1861174088 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CHAD HENDRICKS Credentialing 612-859-0444 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223P0221X Dentist Pediatric Dentistry |
| Additional Taxonomies | 1223G0001X Dentist General Practice |
| Enumeration Date | 2023-08-07 |
| Last Update Date | 2023-08-07 |