| NPI | 1902032246 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CHARLES JARED RANDALL Owner 208-716-3690 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223X0400X Dentist Orthodontics and Dentofacial Orthopedics (Licence: ID D-3405-OR) |
| Enumeration Date | 2009-06-01 |
| Last Update Date | 2009-06-01 |