| NPI | 1609089937 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | HANNAH FISH Credentialing Manager 217-540-5699 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 15772) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 20135) |
| 1223G0001X Dentist General Practice (Licence: TX 20748) | |
| 1223G0001X Dentist General Practice (Licence: TX 16034) | |
| Enumeration Date | 2007-05-07 |
| Last Update Date | 2024-07-09 |