| NPI | 1629508734 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KEVIN LLOYD FATLAND Dentist/President 708-839-8662 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice (Licence: 19025070) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice |
| Enumeration Date | 2017-06-13 |
| Last Update Date | 2017-06-13 |