| NPI | 1265959837 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TABATHA FORREST LEMKE Credentialing COO Rdinator 217-540-8946 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice |
| Enumeration Date | 2017-08-24 |
| Last Update Date | 2022-07-21 |