| NPI | 1417221532 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | GERALD WAYNE DORTCH Owner 618-257-9189 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: IL 019016287) |
| Enumeration Date | 2012-03-07 |
| Last Update Date | 2012-03-07 |