| NPI | 1063899417 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BEAU G MOODY Dentist/Owner 618-659-0456 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center Dental (Licence: IL 019028093) |
| Enumeration Date | 2015-05-05 |
| Last Update Date | 2023-07-24 |