| NPI | 1053582189 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JENNIFER R KREID Dsgp Program COO Rdinator 618-453-8823 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223D0001X Dentist Dental Public Health |
| Additional Taxonomies | 261QD0000X Clinic/Center Dental |
| Enumeration Date | 2008-03-17 |
| Last Update Date | 2025-06-03 |