| NPI | 1013288703 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | FORREST FARR Owner 618-222-8887 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: IL 019026486) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019026532) |
| Enumeration Date | 2012-01-26 |
| Last Update Date | 2014-06-05 |