| NPI | 1376963231 |
|---|---|
| Doing Business As | MYDENTIST-STATE AVE. |
| Entity Type | Organization |
| Authorized Contact | KENDRA WALKER Credentialing Coordinator 217-540-8312 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Enumeration Date | 2014-04-18 |
| Last Update Date | 2014-04-18 |