| NPI | 1619289360 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BRANDON ALEXANDER TAYLOR Credentialing & Payer Relations Man 847-453-7396 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center Dental |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: TX 22535) |
| Enumeration Date | 2010-07-10 |
| Last Update Date | 2021-10-15 |