| NPI | 1124917836 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CLARK PETERSEN Director Of Infrastructure 618-402-6622 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QS0112X Clinic/Center, Oral and Maxillofacial Surgery |
| Enumeration Date | 2025-06-30 |
| Last Update Date | 2025-06-30 |