| NPI | 1962044560 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | SADE RENEE KEITH Credentialing Specialist 919-238-6833 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Additional Taxonomies | 1223P0300X Dentist, Periodontics |
| 1223P0700X Dentist, Prosthodontics | |
| 1223S0112X Dentist, Oral and Maxillofacial Surgery | |
| 122300000X Dentist | |
| 1223E0200X Dentist, Endodontics | |
| 1223P0221X Dentist, Pediatric Dentistry | |
| Enumeration Date | 2019-10-15 |
| Last Update Date | 2021-06-15 |