| NPI | 1578071817 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | NATHAN D LEISKE Owner 618-997-0127 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental (Licence: IL 019.030942) |
| Enumeration Date | 2018-01-22 |
| Last Update Date | 2022-09-19 |