Provider First Line Business Practice Location Address: 
618TH DENT CO (AS)
    Provider Second Line Business Practice Location Address: 
UNIT # 15653, CRC
    Provider Business Practice Location Address City Name: 
APO
    Provider Business Practice Location Address State Name: 
AP
    Provider Business Practice Location Address Postal Code: 
96258-5653
    Provider Business Practice Location Address Country Code: 
KR
    Provider Business Practice Location Address Telephone Number: 
7326910
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/06/2005