| NPI | 1023148681 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CELIA HAYES Credentialing COO Rdinator 217-540-2100 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice |
| Additional Taxonomies | 1223P0221X Dentist Pediatric Dentistry |
| 1223P0300X Dentist Periodontics | |
| Enumeration Date | 2007-03-06 |
| Last Update Date | 2022-03-14 |