| NPI | 1053976605 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MARLEY BRAKER Provider Credentialing Team Leader 414-808-3031 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice |
| Enumeration Date | 2019-05-08 |
| Last Update Date | 2023-12-12 |