| NPI | 1356000368 |
|---|---|
| Doing Business As | LAKE JESUP DENTAL CARE |
| Entity Type | Organization |
| Authorized Contact | CELIA HAYES Credentialing Coordinator 217-540-2100 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Enumeration Date | 2021-12-17 |
| Last Update Date | 2021-12-17 |