| NPI | 1881334175 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SHERRIE EDMONDSON Manager, Licensing & Credentialing 629-999-5014 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Additional Taxonomies | 122300000X Dentist |
| 261QD0000X Clinic/Center, Dental | |
| Enumeration Date | 2022-04-01 |
| Last Update Date | 2022-04-06 |