| NPI | 1750250056 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JULI RENEE MIETZNER Credentialing Manager 217-540-5651 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Enumeration Date | 2025-11-04 |
| Last Update Date | 2025-11-04 |