| NPI | 1902205768 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | HALEY WOOSTER Enrollment Specialist 712-733-8551 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Additional Taxonomies | 122300000X Dentist (Licence: TX 21124) |
| Enumeration Date | 2014-08-18 |
| Last Update Date | 2021-11-17 |