| NPI | 1851415178 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | GARY WAYNE GUSTAVSON President 847-675-3311 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: IL 01915094) |
| Enumeration Date | 2007-03-19 |
| Last Update Date | 2008-08-12 |