| NPI | 1609259266 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BRANDON TAYLOR Credentialing & Payor Relations Mgr 847-453-7396 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: WI 1001130) |
| Enumeration Date | 2015-07-01 |
| Last Update Date | 2021-07-08 |