| NPI | 1710109145 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DONALD J PROVENZALE Partner 630-969-7711 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: IL 19021170) |
| Additional Taxonomies | 1223G0001X Dentist General Practice (Licence: IL 19A12314) |
| Enumeration Date | 2007-05-03 |
| Last Update Date | 2020-08-22 |