| NPI | 1326423468 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CLARK A. PETERSEN Business Manager 618-402-6622 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: TX 30862) |
| Enumeration Date | 2015-07-29 |
| Last Update Date | 2015-07-29 |