| NPI | 1659140515 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MEGAN M TAYLOR Revenue Credentialing Specialist 618-512-1803 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center Dental |
| Enumeration Date | 2023-12-20 |
| Last Update Date | 2023-12-20 |