| NPI | 1902321045 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TANNER MARK CLARK President 208-317-8555 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: UT 9860439-9921) |
| Enumeration Date | 2017-08-10 |
| Last Update Date | 2022-07-21 |