| NPI | 1558710269 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MARLEY BRAKER Provider Credentialing Specialist 414-808-3031 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental |
| Enumeration Date | 2016-06-03 |
| Last Update Date | 2019-05-08 |