| NPI | 1902455694 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JOSUE MORAN Credentialing Specialist 909-723-1044 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice |
| Additional Taxonomies | 1223S0112X Dentist Oral and Maxillofacial Surgery |
| Enumeration Date | 2019-09-05 |
| Last Update Date | 2021-09-22 |