| NPI | 1962000323 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ANDREW WEAVER Credentialing Manager 904-395-7772 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223P0221X Dentist, Pediatric Dentistry |
| Additional Taxonomies | 1223G0001X Dentist, General Practice |
| Enumeration Date | 2020-10-16 |
| Last Update Date | 2024-11-05 |