| NPI | 1003160664 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BRANDON ALEXANDER TAYLOR Credentialing Payer Relations Mgr 847-453-7396 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental |
| Enumeration Date | 2012-11-05 |
| Last Update Date | 2021-10-14 |