| NPI | 1871918078 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CASSANDRA PETERSON Credentialing Team Lead 217-540-8972 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Enumeration Date | 2014-02-25 |
| Last Update Date | 2017-11-02 |