| NPI | 1952454878 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | DALE CHARLES NICKELSEN President 847-695-1693 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental (Licence: IL 060000887) |
| Enumeration Date | 2007-01-22 |
| Last Update Date | 2020-08-22 |