| NPI | 1245605542 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CANDACE WILDE Practice Administrator 219-210-3495 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: IN 12009857A) |
| Enumeration Date | 2015-12-11 |
| Last Update Date | 2015-12-11 |