| NPI | 1205287067 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BRANDON ALEXANDER TAYLOR Credentaling & Payer Relations Mgr 847-453-7396 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: IA 09227) |
| Additional Taxonomies | 261QD0000X Clinic/Center Dental |
| Enumeration Date | 2016-06-23 |
| Last Update Date | 2021-06-24 |