| NPI | 1528259009 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KENDRA WALKER Credentialing Supervisor 217-540-8312 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: AZ 6416) |
| Enumeration Date | 2007-08-08 |
| Last Update Date | 2016-11-18 |