| NPI | 1891316535 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | RANDALL E WILSON Owner 618-236-0501 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental |
| Additional Taxonomies | 332B00000X Durable Medical Equipment & Medical Supplies |
| Enumeration Date | 2020-05-05 |
| Last Update Date | 2025-07-23 |