| NPI | 1578983425 |
|---|---|
| Doing Business As | MYDENTIST-104TH |
| Entity Type | Organization |
| Authorized Contact | HANNAH FISH Credentialing Coordinator 217-540-5699 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Enumeration Date | 2014-04-18 |
| Last Update Date | 2016-04-27 |