| NPI | 1396899878 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BRADLEY WANE ROBERTS President 618-465-9000 |
| Organization Subpart ? | No |
| Primary Taxonomy | 204E00000X Oral & Maxillofacial Surgery (Licence: IL 019019769) |
| Enumeration Date | 2007-01-22 |
| Last Update Date | 2020-08-22 |