| NPI | 1992553499 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ANTHONY MONGILLO Manager 208-542-1333 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223X0400X Dentist, Orthodontics and Dentofacial Orthopedics |
| Additional Taxonomies | 1223P0221X Dentist, Pediatric Dentistry |
| Enumeration Date | 2024-05-09 |
| Last Update Date | 2024-05-09 |