| NPI | 1972901163 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ANGELA LYNN DEHAVEN Owner 765-642-7717 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: IN 12009405) |
| Enumeration Date | 2014-12-20 |
| Last Update Date | 2014-12-23 |