| NPI | 1912502212 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MELISSA BOVEY Credentialing Specialist 800-468-9118 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry |
| Additional Taxonomies | 122300000X Dentist |
| 261QF0400X Clinic/Center, Federally Qualified Health Center (FQHC) | |
| Enumeration Date | 2020-12-03 |
| Last Update Date | 2020-12-03 |