| NPI | 1942501911 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DAWN MICHELLE SHUDT Office Manager 618-465-8100 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: IL 019013894) |
| Additional Taxonomies | 122300000X Dentist (Licence: IL 019028117) |
| 122300000X Dentist (Licence: IL 19020630) | |
| Enumeration Date | 2010-11-08 |
| Last Update Date | 2010-11-08 |