| NPI | 1619739679 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CEMYIRA MCDOUGAL Credentialing COO Rdinator 217-764-8609 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist General Practice |
| Enumeration Date | 2024-01-25 |
| Last Update Date | 2025-03-14 |