| NPI | 1114477353 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CELIA HAYES Credentialing COO Rdinator 217-540-2100 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist Oral and Maxillofacial Surgery (Licence: TX 15919) |
| Enumeration Date | 2016-10-12 |
| Last Update Date | 2022-01-19 |