| NPI | 1164986113 |
|---|---|
| Doing Business As | NORTHLAKE FAMILY DENTISTRY |
| Entity Type | Organization |
| Authorized Contact | PIYANUT ITARUT Organizer 618-977-6071 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental |
| Enumeration Date | 2019-01-24 |
| Last Update Date | 2019-01-24 |