| NPI | 1871002261 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | STACEY MUND CFO 817-916-4431 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Additional Taxonomies | 122300000X Dentist |
| 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics | |
| 261QD0000X Clinic/Center, Dental | |
| Enumeration Date | 2017-09-28 |
| Last Update Date | 2022-08-26 |