| NPI | 1285242693 |
|---|---|
| Doing Business As | INNOVATIVE SMILES AT THE FORUM |
| Entity Type | Organization |
| Authorized Contact | TABATHA LEMKE Credentialing Coordinator 217-540-6078 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Enumeration Date | 2020-07-22 |
| Last Update Date | 2020-07-22 |