| NPI | 1942462080 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BRANDON ALEXANDER TAYLOR Credentialing & Payer Relations Man 847-453-7396 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019026920) |
| Enumeration Date | 2008-06-30 |
| Last Update Date | 2021-06-25 |