Provider First Line Business Practice Location Address:
DENTAC BLDG 2441 21ST STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT CAMPBELL
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42223-5369
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-798-8614
Provider Business Practice Location Address Fax Number:
270-798-8633
Provider Enumeration Date:
04/04/2006