| NPI | 1922726280 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CORY J LARSON Owner 612-789-2853 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist |
| Additional Taxonomies | 332BC3200X Durable Medical Equipment & Medical Supplies Customized Equipment |
| Enumeration Date | 2022-08-22 |
| Last Update Date | 2022-08-22 |