| NPI | 1992361851 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CATHERINE JENSEN Provider Relations Specialist 800-544-2345 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental |
| Enumeration Date | 2019-05-16 |
| Last Update Date | 2019-05-16 |